Health Care Reform Articles - July 2, 2019

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor

by Wendi C. Thomas - Pro Publica - June 27, 2019 

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica’s Big Story newsletter to receive stories like this one in your inbox as soon as they are published.

MEMPHIS, Tennessee — In July 2007, Carrie Barrett went to the emergency room at Methodist University Hospital, complaining of shortness of breath and tightness in her chest. Her leg was swollen, she’d later recall, and her toes were turning black.

Given her family history, high blood pressure and newly diagnosed congestive heart failure, doctors performed a heart catheterization, threading a long tube through her groin and into her heart.

Her share of the two-night stay: $12,019.

Barrett, who has never made more than $12 an hour, doesn’t remember getting any notices to pay from the hospital. But in 2010, Methodist Le Bonheur Healthcare sued her for the unpaid medical bills, plus attorney’s fees and court costs.

Since then, the nonprofit hospital system affiliated with the United Methodist Church has doggedly pursued her, adding interest to the debt seven times and garnishing money from her paycheck on 15 occasions.

Barrett, 63, now owes about $33,000, more than twice what she earned last year, according to her tax return.

“The only thing that kept me levelheaded was praying and asking God to help me,” she said.

She’s among thousands of patients the massive hospital has sued for unpaid medical bills. From 2014 through 2018, Methodist filed more than 8,300 lawsuits, according to an MLK50-ProPublica analysis of Shelby County General Sessions Court records. Older cases like Barrett’s, which dates back nearly a decade, remain on the court’s docket.

Other hospitals in Memphis and around the country also sue patients. According to a study published Tuesday in the Journal of the American Medical Association, researchers found more than 20,000 debt lawsuits filed by Virginia hospitals in 2017. More than 9,300 garnishment cases occurred that year, and nonprofit hospitals were more likely to garnish wages.

But Methodist’s aggressive collection practices stand out in a city where nearly 1 in 4 residents live below the poverty line.

Its handling of poor patients begins with a financial assistance policy that, unlike many of its peers around the country, all but ignores patients with any form of health insurance, no matter their out-of-pocket costs. If they are unable to afford their bills, patients then face what experts say is rare: A licensed collection agency owned by the hospital.

Lawsuits follow. Finally, after the hospital wins a judgment, it repeatedly tries to garnish patients’ wages, which it does in a far higher share of cases than other nonprofit hospitals in Memphis.

Its own employees are no exception. Since 2014, Methodist has sued dozens of its workers for unpaid medical bills, including a hospital housekeeper sued in 2017 for more than $23,000. That year, she told the court, she made $16,000. She’s in a court-ordered payment plan, but in the case of more than 70 other employees, Methodist has garnished the wages it pays them to recoup its medical charges.

Nonprofit hospitals are generally exempt from local, state and federal taxes. In return, the federal government expects them to provide a significant community benefit, including charity care and financial assistance.

Methodist does provide some charity care — and pegs its community benefits as more than $226 million annually — but experts faulted it for also wielding the court as a hammer.

“If Warren Buffett walks in and needs a heart valve procedure and then stiffs the hospital, then yes, you should sue Warren Buffett,” said John Colombo, a University of Illinois College of Law professor emeritus who has testified before Congress about the tax-exempt status of nonprofit hospitals. “I can’t think of a situation in which thousands of your patients would fit that.”

Several nonprofit hospitals don’t sue patients at all, such as Bon Secours Hospitals in Virginia, which stopped pursuing debt suits in 2007, and the University of Pittsburgh Medical Center, which includes more than 20 facilities.

Some of Methodist Hospital’s cousins — health systems affiliated with the United Methodist Church — also don’t sue patients. That’s the case with Methodist Health System, which operates four hospitals in the Dallas area. The collection policy of the seven-hospital Houston Methodist system states: “At no time will Houston Methodist impose extraordinary collection actions such as wage garnishments,” liens on homes, or credit bureau notification.

“We are a faith-based institution and we don’t believe taking extraordinary measures to seek bill payments is consistent with our mission and values,” a Houston Methodist spokesperson said by email.

Methodist Le Bonheur, which says it is the second largest private employer in Shelby County, boasts on its website that it’s committed to a “culture of compassion.” Last year, Fortune magazine ranked the hospital among the 100 Best Companies to Work For.

Methodist declined repeated requests to interview its top executives.

Instead it sent a statement that said, “Outstanding patient debts are only sent to collections and then to court as a very last resort, and only after continued efforts to work with the patients have been exhausted.”

“We strongly believe in providing exceptional care to all members of the community — regardless of ability to pay.”

Methodist’s collection activities are playing out in the second-poorest large metropolitan area in the nation, where jobs have long been concentrated in low-wage industries such as warehousing and logistics. More than 40% of Memphis workers earn less than $15 an hour, according to one economic development report.

For the rest of this year, MLK50 and ProPublica will explore how hospitals, businesses and others in Memphis make it nearly impossible for low-income workers to make ends meet.

Beverly Robertson, who served on Methodist’s board from 2003 to 2012, said she was surprised to learn from a reporter about the hospital’s collection practices. During her lengthy tenure, she said, board members were never informed about the lawsuits against patients.

“I wish I’d known some of this,” said Robertson, president and CEO of the Greater Memphis Chamber and previously executive director of the National Civil Rights Museum.

The Rhythm of General Sessions Court

On Jan. 16, Barrett appeared in Shelby County General Sessions Court to try to stop Methodist’s latest attempt to garnish her paycheck from her part-time job at Kroger, where she makes $9.05 an hour.

She had plenty of company: All 80 lawsuits on the Division 5 docket that morning had been filed by Methodist.

On this morning, Barrett faced Judge Betty Thomas Moore, who has been on the bench for nearly 21 years. Moore expeditiously moved through cases, pausing occasionally to question defendants or lecture them on money management, and to ask Methodist’s attorneys what judgment amount they sought or the monthly payment they’d accept.

Barrett, a devout woman whose denomination eschews makeup and jewelry, stood when Moore called her name.

She waited as the judge flipped through her file, which contained a record of the case, including a motion she filed to reinstate her payments at $40 a month. That’s the amount a judge approved two years earlier, but Barrett had stopped making payments after she lost her job.

Barrett had submitted a sworn affidavit of income and property, which spelled out her dependents, bank account balances, debts, assets and monthly expenses. Barrett wrote that her checking account had $20 in it. Her monthly income was $750 per month, and her expenses were about twice that.

What caught the judge’s eye, though, was the amount owed to the hospital.

“It’s over a $30,000 balance,” Moore said, incredulously. “It has actually doubled.”

Though Barrett had made sporadic payments, they were dwarfed by the mountains of interest the hospital tacked onto her account.

It wasn’t that she didn’t want to pay, Barrett tried to tell the judge, but that she couldn’t. She had to stop working to care for her sister, who died of cancer in November.

“You gotta pay,” replied Moore tersely. She too is a Christian, and from the bench, she often gives God credit for her journey from humble beginnings in South Memphis to elected office. Barrett began to tell the judge that now that she had a new job, she could pay more reliably, but Moore cut her off.

“That I don’t want to hear. … It’s your fourth motion. One time, you just didn’t show up!” Moore said, as Barrett started coughing — a nervous reaction, she explained later.

“Have a seat, ma’am,” said an irritated Moore. “I’m going to think about it for a minute.”

Lots of lawsuits and garnishments

Between 2014 and 2018, more than 163,000 debt lawsuits were filed in Shelby County General Sessions Court, primarily by debt buyers, auto loan companies and hospitals.

Only one plaintiff, Midland Funding, which buys unpaid debt, sued more frequently than Methodist. (Midland declined to comment.)

Methodist filed more than 8,300 lawsuits, compared with more than 6,700 filed by competitor Baptist Memorial Health Care and just over 1,900 by Regional One Health, the county’s public hospital. St. Jude Children’s Research Hospital, also headquartered in Memphis, doesn’t bill families for care not covered by insurance.

With $2.1 billion in revenue and a health system that includes six hospitals, Methodist leads the market: In 2017, it had the most discharges per year and profits per patient, according to publicly available data analyzed by Definitive Healthcare, an analytics company. Methodist says it has “a hospital in all four quadrants of the greater Memphis area, unparalleled by any other healthcare provider in our region,” plus more than 150 outpatient centers, clinics and physician practices.

The number of lawsuits Methodist files isn’t out of proportion to its size, at least compared to Baptist or Regional One. But where it does stand out is the share of cases in which it seeks a wage garnishment order, an action that can upend the lives of low-wage defendants.

A court-ordered garnishment requires that the debtor’s employer send to the court 25% of a worker’s after-tax income, minus basic living expenses and a tiny deduction for children under 15. The court then sends that payment to the creditor.

Methodist secured garnishment orders in 46% of cases filed from 2014 through 2018, compared with 36% at Regional One and 20% at Baptist, according to an analysis of court records by MLK50 and ProPublica. It is unclear what explains this difference.

Turning to the legal system to settle debts is a choice, not a mandate, said Jenifer Bosco, staff attorney at the National Consumer Law Center, a nonprofit focusing on consumer law for low-income and other disadvantaged people. “A lot of medical debts are just handled through the collections process,” she said. “Certainly some end up in court, but it seems like this hospital is especially aggressive.”

Methodist’s Dogged Pursuit of the Poor

Barrett has worked only low-wage jobs, be it cleaning medical offices or sorting packages at FedEx’s largest distribution facility, known as the hub.

But for the last nine years, Methodist has been on Barrett’s trail, following her from one low-wage job to another.

To successfully garnish a debtor’s paycheck, Methodist, like all creditors, has to clear two hurdles. First, the hospital needs to know where the person works, since garnishment requires the employer’s cooperation.

Next, the debtor must have enough after-tax income to clear the law’s earnings exemption, which protects $217.50 per week of a debtor’s after-tax income – the equivalent of 30 hours at the federal minimum wage of $7.25 an hour.

At first, the hospital couldn’t figure out where Barrett worked. It filed garnishment attempts at FedEx and then at Sodexo, which provides housekeeping and other services for corporations, only to learn from the companies that Barrett hadn’t worked there in years.

By September 2011, Barrett was working at T.J.Maxx, tagging clothes headed for the clearance racks. Methodist served her employer with a garnishment attempt, only to run into the second hurdle: She often didn’t make enough to have her pay garnished.

Time and again over the next six years, the hospital tried to garnish Barrett’s pay. Sometimes it succeeded, once collecting $3.67. Other times it failed. Four times, T.J.Maxx returned the garnishment order to the court, marking “Net Earnings Less Than Exemptions.”

While state law spares the poorest debtors from wage garnishment, it doesn’t stop creditors from adding interest to the underlying debt.

Methodist knew that Barrett was a low-income worker, yet it added interest to her account seven times, in amounts ranging from $46 to $7,340.

Charging that much interest to a low-income patient is “unconscionable,” said Fred Morton, a retired minister of Christ United Methodist Church in East Memphis.

“That’s a 21st-century version of slavery,” said Morton, who serves on the economic justice committee for MICAH, a coalition of community and faith-based organizations. “That kind of indebtedness. … That’s horrible to me.”

By 2017, Barrett had moved in with a friend and her mother, both amputees, and cared for them in exchange for a place to stay.

In April of that year, Barrett filed a motion to stop the wage garnishment and offered to pay $40 per month. She told the court her income was $800 per month.

The judge agreed, but then Barrett’s sister, who was unmarried and never had children, fell ill. When Barrett stopped working to care for her, she fell behind on her payments.

“I went and borrowed money through those payday loans to make those payments,” she said. “It was just a struggle for me.”

Every 30 days, she pays $60 to renew the $300 loan, at an effective annual interest rate of more than 240%.

Financial Assistance Required, but Is It Offered?

The Affordable Care Act, former President Barack Obama’s signature health care legislation, is best known for expanding access to health insurance coverage. But it also imposed new requirements on nonprofit hospitals, namely that they have charity care policies and share them with patients.

But the rules do not specify how generous those policies must be — and Methodist is among the least generous in the state, according to MLK50-ProPublica’s review of policies at Tennessee nonprofit hospitals.

While dozens of hospitals offer free or highly discounted care that helps shield low- and middle-income patients, regardless of insurance status, from crushing debt, Methodist does not.

That’s especially problematic for people with high-deductible health insurance plans, defined by the IRS as those with deductibles over $1,350 for an individual and over $2,700 for a family. The number of adults with employer-based, high-deductible health insurance nearly tripled from 2007 through 2017, according to a 2018 report from the Centers for Disease Control and Prevention.

Methodist said it is required by insurers to collect copayments and deductibles. That said, the hospital added: “We know some insured patients have high copays and deductibles that place a financial burden on the patient. As a mission-driven organization, we will work with these patients seeking assistance.”

Methodist’s financial assistance policy is outdated, said Michele Johnson, executive director of the Tennessee Justice Center, which advocates for expanded health care access.

“Methodist’s rules were written at a time when there was just not this epidemic of underinsured people in the state,” Johnson said. “The reality has changed faster than their policy has changed.”

Methodist said it offers 0% interest payment plans for insured and uninsured patients who have trouble paying their bills, but only offers those before court action commences. Methodist also noted that it provides an automatic 70% discount it provides to those who identify as uninsured and the free care to patients at or below 125% of the federal poverty guidelines, which for a single adult would be just over $15,600. Uninsured patients who earn more than that, but less than twice the poverty limit, are also eligible for discounts.

“We are committed to working with all patients who are struggling with medical expenses. Our desire is to work with patients early in the process to set up a payment plan that meets their individual need,” the hospital said in a statement.

The hospital’s contentions, however, do not match the text of its financial assistance, billing and collections policies or the frequently asked billing questions on the hospital’s website. None of those mention interest-free payment plans.

Methodist, like its peers, also gets assistance from the state of Tennessee to help offset its costs for providing uncompensated care. In the first three months of 2019, the state gave more than $31 million to qualifying hospitals. Of that, Methodist Le Bonheur Healthcare’s hospitals received nearly $5 million, according to a quarterly report submitted to the Tennessee General Assembly.

For years, nonprofit hospitals that sue hundreds of patients have been the subject of investigative reports and lawmakers’ scrutiny.

A 2014 ProPublica report on Mosaic Life Care (formerly Heartland Regional Medical Center) in Missouri revealed that the small hospital filed 11,000 lawsuits over a five-year period. Following the story and a Senate investigation led by Sen. Chuck Grassley, R-Iowa, Mosaic rewrote its financial assistance policies and erased nearly $17 million of patients’ debt.

“We were doing the medically right thing for the person, but on the financial responsibility part, we were doing the wrong thing,” Dr. Mark Laney, president and CEO of Mosaic, told the St. Joseph News-Press at the time.

Aggressive debt collection practices are “contrary to the philosophy behind tax exemption,” Grassley wrote in a September 2017 op-ed for the medical and science news outlet Stat.

“Such hospitals seem to forget that tax exemption is a privilege, not a right. In addition to withholding financial assistance to low-income patients, they give top executives salaries on par with their for-profit counterparts.”

In 2017, Methodist paid its president and CEO, Dr. Michael Ugwueke, $1.6 million in total compensation. That same year, Gary Shorb, the hospital’s CEO from 2001 to 2016, earned more than $1.2 million for serving as Ugwueke’s adviser. In 2018, the hospital brought in $86 million more than it spent, according to an end-of-year revenue bond disclosure statement.

Methodist Sends a Defendant in Circles

Across the country, medical debt is common, but it falls hardest on nonwhite residents and people who live in the South, according to the Debt in America report released by the Urban Institute, a Washington, D.C.-based think tank.

In Shelby County, twice as many nonwhite county residents have medical debt in collections as white residents — 23% compared with 11%.

More than half the county’s residents are African Americans, as were more than 90% of Methodist’s defendants observed by a reporter in court this year.

That includes Raquel Nelson, who appeared in court the same morning as Barrett.

Nelson’s employer-provided health insurance covered the majority of a hospital bill for her 2016 hysterectomy, but she still owes $2,200.

This was not the first time Nelson had been a defendant. Methodist sued her in 2013 for $850 in hospital bills for her children, who are now grown. (She has since paid off that debt.) Three years ago, Baptist sued her for $5,000 after an overnight stay for chest pains. She’s paying $50 a month.

Nelson, 43, doesn’t regret choosing a career in social services, although her bachelor’s and master’s degrees left her with $100,000 in student loans, which are in deferment.

Prescriptions to treat chronic illnesses including hypothyroidism, plus supplies for a machine to treat sleep apnea, total more than $200 a month.

When money is tight, Nelson pays just enough on her utility bill to keep the lights on. Her June utility bill was more than $500, and about $200 is the past due amount.

She can’t bring herself to keep a written budget. “If I do, it’ll be frightening because I’ll be thinking, ’How am I even surviving?’”

When a process server handed her the warrant on Dec. 4, stating she’d been sued by Methodist, he also gave her a card to call Consolidated Recovery Systems, a subsidiary of Revenue Assurance Professionals, the licensed debt collection agency owned by Methodist. She called the hospital’s collection agency and was told that if she didn’t pay $175 per month, she could meet them in court.

So Nelson went to court, where she asked the hospital to send her an itemized bill, so she could verify the debt was hers.

She returned to court in April, agreed the debt was hers and the next week filed a motion to pay $75 a month, the same amount she’d offered the collection agency.

In May, Nelson was back in court, this time before Judge John Donald. “I’m nervous,” she whispered, as Donald raced through the cases.

She stood when the judge called her name. Donald asked Methodist’s attorney if $75 a month would be acceptable.

“That’s fine, your honor,” said Dewun Settle, one of two attorneys Methodist has hired to represent the hospital in court.

“You’re free to go,” Donald said, waving Nelson toward the door.

Outside the courtroom, Nelson tallied her costs, including time off work, parking fees for three trips to court and a $27 filing fee all for Methodist’s lawyers to agree to the same monthly payment the hospital’s collection agency refused.

“They were just being greedy,” she said.

A Familiar Rhythm

Methodist’s attorneys tag team the cases. Settle presents the cases to the judge. R. Alan Pritchard moves between the courtroom and the hallway, where he negotiates payment plans with defendants. Attorney’s fees add 33% to the initial hospital bill in each case, turning a $2,000 bill into a $2,660 lawsuit, before court fees and interest.

The judges’ rulings will follow the defendants for months, years, even decades. But Settle doesn’t need to say much for the judge to be the hospital’s heavy.

He usually asks for more than the defendant offered, and then the judges almost always lean on the defendant.

In February, Judge Deborah Henderson was unmoved as a charter school employee explained that student loans and caring for her ailing mother kept her from paying any more than $40 per month.

“It is admirable that you are helping your disabled mom, but there is a difference between a moral responsibility and a legal responsibility,” Henderson said. “This debt is your legal obligation,” she said, before ordering the educator to pay $75 per month.

The defendant left the courtroom in tears.

Even when a defendant complies with a court order and pays the amount agreed and on time, Methodist often seeks more.

That’s what happened to a FedEx worker and mother of two the hospital summoned to court in April.

Court records show she’d made her $50 per month payments as scheduled for the past year. The sworn affidavit detailing her finances showed that her monthly expenses were $170 more than her income.

Judge Lonnie Thompson, elected in 1998, had these documents before him as he listened to Settle argue that the mother should pay more.

“She is paying on time,” Settle allowed. “We’re seeking an increase for $100 a month so the balance won’t continue to increase.”

The hospital had added more than $400 since September, raising the defendant’s debt to nearly $7,000.

Thompson turned to the defendant. “Can you pay $75?”

“My house is in foreclosure right now,” she replied.

Thompson pressed her and the defendant grew frustrated.

“I can’t agree to it if I can’t pay,” the defendant said.

“If I sign the order,” Thompson said sternly, “you have to pay it.”

“I mean, I don’t have it to pay,” she replied.

Thompson relented and agreed to let her continue paying $50 a month. Three weeks later, she filed for bankruptcy.

Pritchard and Settle referred questions to Methodist. Henderson and Thompson did not return emails seeking comment.

If a defendant had an attorney, the lawyer might be able to negotiate a discount on the debt or maybe a reduction in the attorney’s fees.

Without counsel, defendants navigate the system on their own, often poorly. When a judge asked one defendant if she was represented by counsel, the defendant pointed to Pritchard, who shook his head.

Of 80 cases on the Jan. 16 docket, only one defendant was represented by a lawyer.

Neither the judge nor the court staffers can give legal advice.

“I was telling my daughter, and she was saying, ‘You need to talk to somebody,’” Barrett recalled. She thought about going to a free legal clinic offered by Memphis Area Legal Services, she said, “but when you’re the only sole support in your household, you can’t just take off days.”

When the Tennessee Justice Center gets the rare call from a patient drowning in hospital bills, Johnson or her staff will call their contacts at that hospital.

“We’ll say, ‘This is a really heartbreaking story,’ and a lot of times they’ll just write the bill off,” she said. “I don’t know if that’s because they know that we know our way to the media, but we don’t necessarily threaten that. But they see us on the news a lot.”

Constrained by the Law

Before she ran for Shelby County General Sessions Court judge in 1998, Moore was a public defender trying capital cases. She was starting to get burned out, but she didn’t want to leave public service.

She won that election and the two since.

Moore has an easy rapport with attorneys Settle and Pritchard. And she tries to maintain a firm, but friendly demeanor with defendants.

In late May, she told a courtroom packed with defendants that she’d been where they are: Sued by creditors and having her wages garnished.

It was back in the 1980s, Moore said during an interview in her chambers, when she was a new attorney with the public defender’s office.

“I had a husband who walked off, left me with the kids, stopped paying child support and kept it moving. And I struggled,” she said.

She filed for bankruptcy in 1995.

Her empathy surfaces on her Facebook page, where she has posted articles about a subprime auto lender and an essay about the insecurity of a life in poverty.

Years ago, she took a stand when she heard cases involving car lenders who charged what she saw as exorbitant interest rates.

“I would strike it out and say: ’32%? That is unconscionable.’ That’s the legal word you can use to say, ‘I ain’t doing it,’” she said.

In response, the creditors’ lawyers sent letters reminding her that the law allowed them to charge the contractual interest rate.

“I just stopped striking it out because there was really no gray area with that. The law said this is what it is.”

Moore said she can’t be — and isn’t — swayed by the relative power of the parties involved, even when the plaintiff is a massive, profitable health care system and the defendants are often poor and without counsel. “If you start factoring that in, then you become biased.”

In April, Moore heard the case of a mother of three who owed more than $3,000. In her slow pay motion, the defendant proposed paying $30 per month.

Moore turned to Settle. “What do y’all need on that?” she asked.

At least $200 a month, Settle replied.

“I can’t do $200,” said the defendant, who works at a warehouse.

Moore then turned to the defendant’s sworn affidavit of income and property. The mother’s $2,000 monthly income left her $1,300 in the red.

Moore zeroed in on the ages of her sons (11, 17 and 19) and the defendant’s sizable clothing allowance and food budget. They were old enough, Moore reasoned, to sacrifice a little so their mother could pay more.

The 11-year-old is autistic, nonverbal, wears diapers and can only eat pureed foods, the mother told the judge. Moore shared that an elderly relative was on a similar diet, but she didn’t cut the defendant a break.

“Even with what you told me, I think you can do $100,” she said, before signing a court order directing the defendant to pay $130 per month.

On the same morning Barrett and Nelson were in court, a Shelby County Schools kindergarten teacher came to confront a $6,800 debt.

Settle asked for $140 per month. The teacher countered with $50 a month, but the judge seemed offended.

“I won’t even consider it,” Moore said. The teacher’s husband, who’d accompanied his wife to court, spoke up, but Moore cut him off.

“You married a grown-ass woman,” Moore snapped.

“Please don’t curse,” the teacher said.

“I apologize,” Moore said quickly. “It’s just frustrating.”

Taped to a door in the judge’s chambers is a prayer that says in part: “Help me to treat others today as I desire to be treated.”

She said she reads it every time she heads to the bench.

“I want to do and say what is right and pleasing to God because sometimes these folk, honey, they’ll make you want to cuss,” she said.

Debt That Will Follow Her to the Grave

After Moore heard the rest of the cases on the docket that January day, she called Barrett’s name again.

Barrett stood, and Settle asked the judge to set her payments at $100 a month.

The judge agreed, denying Barrett’s motion to pay $40 per month.

“This is going to be my last time setting this up,” Moore said sternly. “You gone be paying on this for many, many months to come.”

Months later, Barrett was still bothered by the outcome.

“If you know I can’t pay $40, why you think I can pay $100?” Barrett said.

If she’d had a chance, she would have told the judge she was perpetually late on her utility bill and sometimes, she’s had to let her car insurance lapse because she can’t afford it. “She don’t take but a few seconds to make that sentence. It was just moving them in and moving them out. They don’t have no kind of empathy for people.”

Between February and May, Barrett managed to make her payments on time, by shorting other bills and relying on payday loans. But this month, she missed her payment due date.

If Methodist doesn’t add any interest to Barrett’s debt and she pays as ordered, she will pay it off in 330 months.

She will be 90 years old.

Not long after her day in court, Barrett filed her 2018 taxes.

She made $13,800.

“It’s in the hands of God now,” she said. “There’s only so much I can do.”

Between 2014 through 2018, Methodist Le Bonheur Healthcare, which includes Methodist University Hospital, filed more than 8,300 lawsuits for unpaid hospital bills. Many of the defendants are low-income. (Andrea Morales for MLK50)

https://www.propublica.org/article/methodist-le-bonheur-healthcare-sues-poor-medical-debt?

Which hospitals sue patients for unpaid medical bills?

by The Lown Institute - June 26, 2019

What do hospitals do when patients can’t pay their medical bills? One quarter of American families report having trouble paying their medical bills, and even patients with insurance struggle with paying out-of-pocket costs. While many patients engage in crowdfunding or sacrifice household necessities to pay medical bills, others may not be able to raise the money, and they leave medical bills unpaid.
Hospitals may try to negotiate a lower bill with patients, offer financial assistance, send the bill to a collection agency, or write off unpaid costs as “bad debt.” However, many hospitals go a step further and sue patients for the unpaid bill, eventually garnishing (taking a cut) of their wages or bank savings. Although most of these unpaid bills are a few thousand dollars, the effect on families can be crushing. “I literally have no food in my house because they’re garnishing my check,” said Daisha Smith, who was sued by Mary Washington hospital for an unpaid medical bill, in NPR. Many patients do not even know they have been sued until they discover part of their paycheck is going missing.
How prevalent is the practice of suing patients for unpaid bills, and which hospitals are doing it the most? In a recent research letter in JAMA, researchers at the Johns Hopkins University School of Medicine analyzed court records in Virginia for 2017 to find out how often hospitals were suing patients. They found that hospitals sued patients about 20,000 times in 2017 and garnished their wages more than 9,000 times.
Surprisingly, nonprofit hospitals were much more likely to garnish wages compared to for-profit hospitals; 43 percent of non-profit hospitals garnished wages compared to 33 percent of for-profits and 6% of government-owned hospitals. Out of all the Virginia hospitals that garnished wages in 2017, 71 percent were non-profits. There were a few particularly bad offenders; just four nonprofit hospitals (including Mary Washington hospital) accounted for over half of all lawsuits in Virginia in 2017.
The disproportionate role of non-profit hospitals in garnishing wages is especially disappointing because non-profit hospitals receive significant tax benefits for providing benefits to the community, including financial aid and charity care. As Dr. Martin Makary, one of the co-authors of the research letter, said in NPR, non-profit hospitals are supposed to be a “safe haven for people regardless of one’s race, creed or ability to pay.” When a nonprofit hospital uses its power to impose a financial burden on families that can’t afford to pay medical bills, “it’s a disgrace,” said Makary.
https://lowninstitute.org/news/blog/which-hospitals-sue-patients-for-unpaid-medical-bills/

MEDICAL PROFESSIONALISM: WHO NEEDS IT?

by Dan Bryant - Maine Medical Center Journal - July, 2019

Asuccessful twenty-something doesn’t remember his doctor’s name. Books like How to Survive Your Doctor’s Care and articles like “Does the Doctor Work for You?” appear. Studies find decreasing respect for physicians.1,2 This evidence of loss of respect could be partly explained by a decline, or a perception of decline, in medical professionalism. As the former president of the Association of American Medical Colleges observed, “professionalism...is the medium through which individual physicians fulfill the lofty expectations that society has of medicine.”3
During my medical training in the 1960s, “medical professionalism” meant some combination of autonomy of the physician and primacy of the individual patient. Indeed, the AMA’s 1957 Principles of Medical Ethics stated both that, “A physician may choose whom he will serve,” and that physicians shall render to each patient “a full measure of service and devotion.”4 A 2001 revision added, “A physician shall support access to medical care for all people.”4 And the ABIM Foundation’s 2002 Physician Charter declared “patient welfare,” “patient autonomy,” and “social justice” to be fundamental elements.5 In 2006, Stern summarized medical professionalism as “excellence, humanism, accountability, and altruism.”6 More recently, the American Board of Medical Specialties emphasized the physician’s responsibility “to serve patients’ and the public’s interests, and not merely the self-interests of practitioners;” as well as “to work together with patients, eliciting goals and values to direct the proper use of the profession’s specialized knowledge and skills.”7
If medical professionalism—this new, outward- looking medical professionalism—is in decline, what might be the cause?
The corporatization and retailization of medicine is one possibility. As Pellegrino has observed,
Correspondence: Daniel C. Bryant, MD
7 Rock Wall Lane, Cape Elizabeth, ME 04107 bryantdc57@gmail.com
“health care is not a commodity...health is a
human good that a good society has an obligation
8
to protect from the market ethos.” Or, as Bryan
puts it, “Marketplace values—for example, profit, competition, consumerism, short-term goals, creating demand through advertising, and seeking power through monopoly—diametrically oppose professionalism in its highest sense.”9
A related effect of corporatization is that on medical education. As mergers and acquisitions emphasize productivity in teaching hospitals, it is “easy for... patients to be viewed as customers buying products rather than suffering human beings.”10 Doctors in training may absorb this hidden curriculum, just as I absorbed mine back when, and unwittingly let it influence their future behavior.
The multi-payer system, especially its commercial insurance component, may challenge medical professionalism. A 1999 study of physician behavior toward insurers “found a tension between the traditional ethic of patient advocacy and the new ethic of cost control....”11 Job changes can disrupt long-term physician-patient relationships established through employer-based insurance. Skewed reimbursement for care of patients in high- vs. low-risk pools leads some physicians to avoid “state” patients, reducing “access to medical care for all people.” Alternate payment methods may pose ethical dilemmas to physicians, leading patients to suspect “the self-interests of practitioners.”
Societal changes have brought their own threats. Flex-time, job-sharing, and work-life balance strategies offer physicians a way to deal with the paperwork overtaking clinical demands. To some in the public this may look like decreased commitment to the “patient welfare” and “service and devotion” of the old house-call days. The growing suspicion of experts, the patients’ rights movement, headlines about malpractice cases and medical errors, have caused some in the public to question physicians’ “proper use of the profession’s specialized knowledge and skills,” if not their ethical values generally. Economic forces increasing educational  debt have taken a toll, too: “... it can be argued that even the current extent of partial financing of their education by medical students has so indebted them as to place the profession’s traditional ethos in peril.”12
Even government actions have jeopardized medical professionalism. In 1965, Medicare brought more and sicker patients to doctors, and documentation burdens have increased since, reducing time for doctor-patient bonding. Restriction of Medicare funding to only in-patient education has limited the teaching of long-term “work[ing] together with patients,” while reductions in such funding overall reduces opportunities for transmitting professional values: “... there is often increased pressure on faculty to concentrate on revenue-generating work rather than on teaching.”12 And the 1999 National Labor Relations Board classification of residents as employees, not students, may have led some trainees to think of their work as business as much as calling. Ironically, medical progress itself may be threatening professionalism. The increased sophistication of medicine means no single physician can manage or even coordinate all of a patient’s problems. Specialization turns some physicians into technicians with little time to establish long-term patient “goals and values.” In the age of hospitalists, primary care doctors have less opportunity to demonstrate that “full measure of service and devotion” that traditionally bonded them to their patients at times of major illness. Technologic advances allow patients to access unfiltered medical information, thus bypassing if not challenging “the profession’s specialized knowledge and skills.” Imaging, email, texts, telemedicine supplant the intimacy of the hands-on, face-to-face engagement so crucial to “working with patients.” The Electronic Medical Record puts physicians at risk of stereotyping and distancing patients, as well as conflating patients’ interests with their own. And as bedside teaching has yielded to digital learning, medical trainees have less exposure to role models’ examples of “eliciting goals and values.”13
These are only some of the corporate, educational, economic, societal, governmental, and occupational threats to the medical professionalism that patients need for their health, and that I maintain physicians need for the public’s respect. Physicians’ responses to these threats include recognizing and calling out the encroachment of marketplace values, fostering long-term and in-depth patient relationships,
backgrounding technology, prioritizing bed-side and exam-room teaching; to which should be added affirming principles of the new medical professionalism: “social justice,” “humanism, accountability, and altruism,” concern for “the public’s interests.” Speaking out in support of “access to medical care for all people,” for example, could go a long way toward reassuring the public that medical professionalism is alive and well, and that, yes, physicians do deserve their respect.
Maybe even more than they did in the good old days.
Conflicts of Interest: None
Keywords: Professionalism, Codes of Ethics,
Public Opinion
REFERENCES
1. Blendon RJ, Benson JM, Hero JO. Public trust in physicians- -U.S. medicine in international perspective. N Engl J Med. 2014;371(17):1570-1572.
2. Schlesinger M. A loss of faith: the sources of reduced political legitimacy for the American medical profession. Milbank Q. 2002;80(2):185-235.
3. Cohen J. Preface. In: Stern DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006: vi.
4. Riddick FA, Jr. The Code of Medical Ethics of the American Medical Association. Ochsner J. 2003;5(2):6-10.
5. Brennan T, Blank L, Cohen J., et. al.; for American Board of Internal Medicine Foundation; American College of Physicians- American Society of Internal Medicine Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243-246.
6. Arnold L, Stern DT. What is medical professionalism? In: Stern DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006:19.
7. Hafferty F, Papadakis M, Sullivan W, Wynia M. The American Board of Medical Specialties Ethics and Professionalism Committee Definition of Professionalism. American Board of Medical Specialties. 2012.
8. Pellegrino ED. The commodification of medical and health care: the moral consequences of a paradigm shift from a professional to a market ethic. J Med Philos. 1999;24(3):243-266.
9. Bryan CS. Medical professionalism meets Generation X: a perfect storm? Tex Heart Inst J. 2011;38(5):465-470; discussion 470. 10. Ludmerer KM. Let Me Heal: The Opportunity to Preserve
Excellence in American Medicine. New York, NY: Oxford
University Press; 2014.
Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy 
DP. Lying for patients: physician deception of third-party payers. 
Arch Intern Med. 1999;159(19):2263-2270. 

Rich EC, Liebow M, Srinivasan M, et al. Medicare financing of 
graduate medical education. J Gen Intern Med. 2002;17(4):283- 
292. 

13.LaCombe MA. On bedside teaching. Ann Intern Med.
1997;126(3):217-220.

Democrat vs. Democrat: How Health Care Is Dividing the Party

An issue that united the party in 2018 has potential to fracture it in 2020.

by Abby Goodnough and Thomas Kaplan - NYT - June 28, 2019

WASHINGTON — It was a command as much as a question, intended to put an end to months of equivocating and obfuscating on the issue: Which of the Democratic presidential candidates on the debate stage supported abolishing private health insurance in favor of a single government-run plan? Show of hands, please.
Just four arms went up over the two nights — Senator Elizabeth Warren of Massachusetts and Mayor Bill de Blasio of New York on Wednesday, and Senators Bernie Sanders of Vermont and Kamala Harris of California on Thursday — even though five candidates who kept their hands at their sides have signed onto bills in Congress that would do exactly that.
And after the debate, Ms. Harris said that she had misunderstood the question, suggesting she had not meant to raise her hand either.
The response, and ensuing confusion, reflected one of the deepest fault lines among Democrats heading into 2020 — on an issue the party hopes to use as a cudgel against President Trump as effectively as it did last fall, when their vow to protect the Affordable Care Act helped them recapture the House.

Though Democrats owned the health care issue in 2018, pointing a way forward — tear up the current system and start over or build on gains in coverage and care that the Obama health law achieved — is proving tricky for the party’s presidential candidates.
The challenge is to avoid alienating both the progressives, whose support they will need in the primary, and the more moderate voters, without whom they cannot survive the general election.

Read more
We surveyed all the candidates for details of their positions on health care. Here’s what they said:

In shooting up her hand and saying, “I’m with Bernie,” Ms. Warren seemed to have made the calculation that proving herself as unequivocal as Mr. Sanders in the quest for universal government-run health insurance was crucial to building the left-wing support she needs, including from some of his loyalists.
During the early months of the Democratic primary race, Ms. Warren has gained attention with her steady stream of detailed policy plans on a variety of subjects. But before Wednesday’s debate, she had been less than crystal clear about how she would expand access to health care — and particularly on the role that private insurers should play under the type of Medicare-for-all system that she is calling for.

“I think lots of progressives were very happy to see her clarify her position,” said Waleed Shahid, the communications director for Justice Democrats, a group that seeks to elect progressive House candidates.
[Read our story about what might happen if we got rid of private health insurance.]
Ms. Harris had more overtly waffled on the future of private insurance before the debates, yet raised her hand just as quickly as Mr. Sanders when one of the moderators asked who favored abolishing it.
After the debate, she immediately walked it back, saying she understood the question to be asking whether she would give up her own private insurance.

Asked point-blank on MSNBC’s “Morning Joe” on Friday morning whether she believed that private insurance should be eliminated in the United States, Ms. Harris responded, “No.”
“I am a proponent of ‘Medicare for all,’” she said. “Private insurance will exist for supplemental coverage.” Mr. Sanders’s Medicare for All Act, which she co-sponsored, would allow private coverage for elective procedures, like cosmetic surgery, not covered by the government plan.
John Delaney, a former Maryland congressman who is also seeking the Democratic presidential nomination, is taking every possible opportunity to warn that the party is at risk of turning health care from a winning issue into a liability.

“We won on health care in 2018, and if we go down the path with Medicare for all, we’ll lose on it in 2020,” he said in an interview. “Right now, about half of our citizens have private insurance and most of them like it. And you just can’t win elections on taking something away from the American people that they like. It’s just not common sense.”
Ironically, support for universal government-run health insurance could provoke the same counterattack from Republicans that the Democrats used so potently after the Trump administration tried to repeal and replace the Affordable Care Act.
“Trump and the Republicans will spend a billion dollars telling the American people that the Democrats want to take away your health insurance,” Mr. Delaney said, “and he would be correct.”
Mr. Trump appears to be adopting just such a strategy. In a recent Rose Garden appearance, he warned that more than 120 Democrats had signed onto Medicare for all legislation — a “massive government takeover of health care,” as he put it — that would expand Medicare to cover all Americans, make the program’s benefits more generous and eliminate most deductibles and co-payments.
“That’s going to hurt a lot of people,” Mr. Trump said. “Their plan would eliminate Medicare as we know it and terminate the private health insurance of 180 million Americans.”
Remaining imprecise on the issue could have been a vulnerability for Ms. Warren in particular as she tries to compete with Mr. Sanders. “Elizabeth Warren Has a Plan for Everything — Except Health Care,” read the headline of a recent article published by Jacobin, the socialist magazine.

But her outright call for eliminating private coverage would create new risks if she were to become the Democratic nominee.

“She didn’t have to fall into that trap,” said Paul Starr, a professor of sociology and public affairs at Princeton who was a health policy adviser in the Clinton White House.
Not only would abolishing private insurance disrupt coverage for many people who are satisfied with their private coverage, Mr. Starr said, but generating the revenue needed to finance a single-payer health care system “would be just an overwhelming political task.”
“If in coming weeks and months it’s that raising of the hand that gets replayed again and again, then I think it’s going to damage her,” he said.
With Mr. Trump and his surrogates likely to step up their attack in the coming months, it was not particularly surprising to hear most of the Democrats walk a more cautious line — even the ones who have co-sponsored Mr. Sanders’s single-payer bill or a House version that would, in fact, put everyone into government-run coverage, including Senator Cory Booker of New Jersey, Senator Kirsten Gillibrand of New York and Representative Tulsi Gabbard of Hawaii.
All three were more vague when questioned about eliminating private insurance. Mr. Booker said he favored keeping it but did not explain why and Ms. Gabbard said merely that it deserved “some form of a role.”
Many candidates — including some who say their ultimate goal is a government-run system — support a system in which people would have the option to buy into Medicare or a similar public insurance program, but private insurers could still compete for their business.

Ms. Gillibrand was eager to point out that she had written the portion of the Sanders bill allowing four years for Americans to transition to their new government coverage by providing such a choice.
“I believe we need to get to universal health care as a right and not a privilege — to single payer,” Ms. Gillibrand said. “The quickest way you get there is you create competition with the insurers. God bless the insurers. If they want to compete, they can certainly try.”
More likely, though, she contended, is that “people will choose Medicare, you will transition, we will get to Medicare for all.”
The hesitancy to fully embrace the abolition of private insurance isn’t surprising considering the polling on the issue, which has consistently found that support for Medicare for all drops off quickly when voters are told it would eliminate their private, employer-provided plans and most likely raise taxes.
The poll results also help explain why so many candidates — including former Vice President Joseph R. Biden Jr., Senator Michael Bennet of Colorado, Mayor Pete Buttigieg of South Bend, Ind., Gov. Jay Inslee of Washington, Senator Amy Klobuchar of Minnesota and former Representative Beto O’Rourke of Texas — say they would keep private insurance but add a “public option” to buy coverage in a government-run health plan that would create competition and potentially drive down prices.
Some candidates support bills that would allow people who do not get insurance through a job, or those 50 and older, to pay a premium to buy a Medicare plan that would be the same as what is now available to people 65 and older. Others prefer the idea of setting up a new public plan, run by the government, that anyone could buy — a “Medicare-for-all-who-want-it” approach.
Mr. Buttigieg used that very phrase on Thursday and suggested he was fine with keeping private insurance for everything but the most basic care.

“Let’s remember,” he said, “even in countries that have outright socialized medicine — like England — even there, there’s still a private sector. That’s fine. It’s just that for our primary care, we can’t be relying on the tender mercies of the corporate system.”
Mr. Biden noted that creating a public option to compete with private insurance could be done much quicker than a complete overhaul of the health care system.
“Urgency matters,” Mr. Biden said, referring to people like his son Beau, who died of brain cancer in 2015. “We must move now.”
https://www.nytimes.com/2019/06/28/health/democratic-debate-healthcare.html

 

The Lessons of Washington State’s Watered Down ‘Public Option’

by Sarah Kliff - NYT - June 27, 2019

A big health care experiment for Democrats shows how fiercely doctors and hospitals will fight. 

by Sarah Kliff - NYT - June 27, 2019

For those who dream of universal health care, Washington State looks like a pioneer. As Gov. Jay Inslee pointed out in the first Democratic presidential debate on Wednesday, his state has created the country’s first “public option” — a government-run health plan that would compete with private insurance.
Ten years ago, the idea of a public option was so contentious that Obamacare became law only after the concept was discarded. Now it’s gaining support again, particularly among Democratic candidates like Joe Biden who see it as a more moderate alternative to a Bernie Sanders-style “Medicare for all.”
New Mexico and Colorado are exploring whether they can move faster than Congress and also introduce state-level, public health coverage open to all residents.
But a closer look at the Washington public option signed into law last month, and how it was watered down for passage, is a reminder of why the idea ultimately failed to make it into the Affordable Care Act and gives a preview of the tricky politics of extending the government’s reach into health care.

On one level, the law is a big milestone. It allows the state to regulate some health care prices, a crucial feature of congressional public option and single-payer plans.
But the law also made big compromises that experts say will make it less powerful. To gain enough political support to pass, health care prices were set significantly higher than drafters originally hoped.
“It started out as a very aggressive effort to push down prices to Medicare levels, and ended up something quite a bit more modest,” said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation.
So while Washington is on track to have a public option soon, it may not deliver the steep premium cuts that supporters want. The state estimates that individual market premiums will fall 5 percent to 10 percent when the new public plan begins.
“This bill is important, but it’s also relatively modest,” said David Frockt, the state senator who sponsored the bill. “When I see candidates talking about the public option, I don’t think they’re really grasping the level of opposition they’re going to face.”

During the Affordable Care Act debate, more liberal Democrats hoped a public option would reduce the uninsured rate by offering lower premiums and putting competitive pressure on private plans to do the same. President Obama backed it, saying in 2009 that such a policy would “keep the private sector honest.”
The public option came under fierce attack from the health care industry. Private health plans in particular did not look forward to competing against a new public insurer that offered lower rates, and fought against a government-run plan that they said “would significantly disrupt the coverage that people currently rely on.” The policy narrowly fell out of the health care law but never left the policy debate.
Congressional Democrats have started to revisit the idea in the past year, with health care as a top policy issue in the 2018 midterm elections.
“During the midterm elections, Medicare for all was gaining a lot of traction,” said Eileen Cody, the Washington state legislator who introduced the first version of the public option bill. “After the election, we had to decide, what do we want to do about it?”
Ms. Cody introduced a bill in January to create a public option that would pay hospitals and doctors the same prices as Medicare does, which is also how many congressional public option proposals would set fees. The Washington State Health Benefit Exchange, the marketplace that manages individual Affordable Care Act plans, estimates that private plans currently pay 174 percent of Medicare fees, making the proposed rates a steep payment cut.
“I felt that capping the rates was very important,” Ms. Cody said. “If we didn’t start somewhere, then the rates were going to keep going up.”
Doctors and hospitals in Washington lobbied against the rate regulation, arguing that they rely on private insurers’ higher payment rates to keep their doors open while still accepting patients from Medicaid, the public plan that covers lower-income Americans and generally pays lower rates.

“Politically, we were trying to be in every conversation,” says Jennifer Hanscom, executive director of the Washington State Medical Association, which lobbies on behalf of doctors. “We were trying to be in the room, saying rate setting doesn’t work for us — let’s consider some other options. As soon as it was put in the bill, that’s where our opposition started to solidify.”
Legislators were in a policy bind. The whole point of the public option was to reduce premiums by cutting health care prices. But if they cut the prices too much, they risked a revolt. Doctors and hospitals could snub the new plan, declining to participate in the network.
“The whole debate was about the rate mechanism,” said Mr. Frockt, the state senator. “With the original bill, with Medicare rates, there was strong opposition from all quarters. The insurers, the hospitals, the doctors, everybody.”
Mr. Frockt and his colleagues ultimately raised the fees for the public option up to 160 percent of Medicare rates.
“I don’t think the bill would have passed at Medicare rates,” Mr. Frockt said. “I think having the Medicare-plus rates was crucial to getting the final few votes.”
Other elements of the Washington State plan could further weaken the public option. Instead of starting an insurance company from scratch, the state decided to contract with private insurers to run the day-to-day operations of the new plan.
“It would have cost the state hundreds of millions of dollars just to operate the plan,” said Jason McGill, who recently served as a senior health policy adviser to Mr. Inslee. He noted that insurers were required to maintain large financial reserves, to ensure they don’t go bankrupt if a few patients have especially costly medical bills.

“Why would we do that when there are already insurers that do that? It just didn’t make financial sense. It may one day, and we’ll stay on top of this, but we’re not willing to totally mothball the health care system quite yet.”
Hospitals and doctors will also get to decide whether to participate in the new plan, which pays lower prices than private competitors. The state decided to make participation voluntary, although state officials say they will consider revisiting that if they’re unable to build a strong network of health care providers.
Most federal versions of the public option would give patients access to Medicare’s expansive network of doctors and hospitals.
Although Mr. Frockt is proud of the new bill, he’s also measured in describing how it will affect his state’s residents. After going through the process of passing the country’s first public option, he’s cautious in his expectations for what a future president and Democratic Congress might be able to achieve. But he does have a clearer sense of what the debate will be like, and where it will focus.
“This is a core debate in the Democratic Party: Do we build on the current system, or do we move to a universal system and how do we get there?” he said. “I think the rate-setting issue is going to be vital. It’s what this is all about.”
https://www.nytimes.com/2019/06/27/upshot/washington-state-weakened-public-option-.html?action=click&module=News&pgtype=Homepage

 

The front line of England's health service is being re-invented

A shortage of family doctors leaves little choice but to try something new

by St Austell - The Economist - June 26, 2019

THE NATIONAL HEALTH SERVICE is free, so it is also rationed. Family doctors, known as general practitioners (GPs), act as the first port of call for patients; friendly gatekeepers to the rest of the service who refer people to specialists only if needed. But in some parts of the country, including St Austell on the Cornish coast, access to the rationers is itself now rationed. “You can’t book an appointment to see me here,” explains Stewart Smith, a 39-year-old GP, one of a team in charge of an innovative new medical centre. “You go on a list and then we triage you.”
It is an approach that will soon be familiar to more patients. Simon Stevens, chief executive of NHS England, has said that being a GP is arguably the most important job in the country. There is, however, a severe shortage of them. According to the Nuffield Trust, a think-tank, there are 58 GPs per 100,000 people, down from 66 in 2009—the first sustained fall since the 1960s. Only half of patients say they almost always see their preferred doctor, down from 65% six years ago. The average consultation lasts just nine minutes, among the quickest in the rich world.

Although the NHS hopes to train and recruit new family doctors, the gap won’t be plugged any time soon. A new five-year contract to fund GP practices will eventually include £891m ($1.1bn) a year for 20,000 extra clinical staff, such as pharmacists and physiotherapists, with the first cash for such roles arriving on July 1st. To access the money, practices will have to form networks, which, it is hoped, will help them take advantage of economies of scale and do more to prevent illnesses rather than treating them.
When the four practices serving St Austell merged in 2015, it was an opportunity to reconsider how they did things. The GPs kept a diary, noting precisely what they got up to during the day. It turned out that lots could be done by others: administrators could take care of some communication with hospitals, physios could see people with bad backs and psychiatric nurses those with anxiety. So now they do. Only patients with the most complicated or urgent problems make it to a doctor. As a result, each GP is responsible for 3,800 locals, compared with an average of 2,000 in the rest of Cornwall.
Although few practices have made changes on the scale of St Austell Healthcare, across England the number of clinical staff other than GPs has grown by more than a third since 2015. The logic behind the introduction of these new roles is compelling, says Ben Gershlick of the Health Foundation, another think-tank. The NHS estimates that 30% of GPs’ time is spent on musculoskeletal problems, for instance, which could often be handled by a physiotherapist. Another estimate suggests 11% of their day is taken up by paperwork. Doctors complain that they are overworked, and growing numbers retire early. They are also expensive: the starting salary for a GP is £57,655, whereas a physio costs around half as much.
NHS leaders hope the new workers will help practices play a more active role in their community, linking up with services provided by local authorities and charities. Each network will be responsible for a population of 30,000-50,000. The plan is that they will use data analysis to intervene early to prevent illness, and that practices will often share the new staff with others in their network.
Those that are further down the road sing the benefits of the new approach. Caroline Taylor of the Beechwood Medical Centre in Halifax says that new roles quickly show their worth. Her practice took in a “work wellness adviser” employed by the council. The adviser’s goal was to help ten people over the age of 50 with poor mental health back to work in a year—a task which she completed in just six weeks. In St Austell two pharmacists last year helped to cut more than £140,000 from prescribing costs. Far fewer staff now report that they are burnt out.
Working in a team will nevertheless require a big shift in mindset for many doctors, particularly those in surgeries that have never before employed anyone else aside from the odd nurse. One worry is that practices will end up doing what they must to get the extra funding, but little more. There are also more practical problems. Seven in ten GPs say their practices are too cramped to provide new services, and it is not clear where some of the extra staff will be hired from.
Perhaps the biggest problem is that patients have grown used to having a doctor on demand. Although those who no longer have to queue for an appointment may be happy, others might feel fobbed off if diverted to another clinician. A study published last year by Charlotte Paddison of the Nuffield Trust, and colleagues, in the British Medical Journal found that patients have less trust in the care provided by a nurse if they initially expected to see a doctor. Patients who have a close relationship with their GP tend to be more satisfied and enjoy better health outcomes than others.
But other evidence suggests that, for some conditions, nurses provide care that is as good or better than that provided by GPs. The aim, says Nav Chana of the National Association of Primary Care, which helped develop the new approach, is therefore to use small teams of doctors and other clinical staff to replicate the sort of relationship with patients that used to be more common. Just parachuting in “a lot of people who look like doctors” will not raise standards, he warns.
The shortage of GPs leaves the NHS with little choice but to try something new. “A lot of the world has either copied or is trying to copy English primary care,” in particular its openness to all and the continuity of care that it provides, says Dr Chana. Keeping these strengths, while changing how primary care works, is the task NHS officials are now facing up to. Even if they succeed, it will take time for the public to adjust. Having explained the benefits of the new way of doing things, one GP pauses, before adding: “I should say, though, patients don’t love it.”

https://www.economist.com/britain/2019/06/26/the-front-line-of-englands-health-service-is-being-re-invented 

Are We Sure Eliminating Private Insurance is a Good Idea? 

by Peter Suderman - NYT - June 28, 2019

It would be an exaggeration to say that the Democratic primary race is entirely about health care, but only a little bit of one. The standout moment from the first evening was Elizabeth Warren’s vociferous defense of eliminating private insurance companies, and much of the first half of last night’s debate was consumed with the issue as well. The candidates onstage were eager to recommend their plans and elaborate on their differences: Perhaps more than any other issue, this was one on which the different policy ideas in play were clear. Democrats were offering voters choices.
That health care would play such a prominent role in the Democratic primary race is hardly surprising, given its role in last year’s midterm election. Exit polls found that health care was the top issue for voters, and even the Republican leadership in the House has seemingly blamed midterm losses on the issue.
Health care, in other words, may have decided the midterm, and is certain to play a pivotal role in the primary. And next year, it could play a pivotal role in the general election, too. But will it help or hurt the Democratic candidate?
In one sense, it offers Democrats an advantage. The party is far more engaged with the details of health care policy, and far more willing to promise to extend coverage to those who don’t have it. The debate over the last two nights has not been about whether to expand health coverage, but by how much, and by what policy mechanism.

From Medicare for All to a public option that builds on Obamacare, Democrats have plenty to say on the issue. That makes for a stark contrast with Republicans, who tried and failed to repeal Obamacare in 2017, and have since instigated a lawsuit designed to take down the law. President Trump has repeatedly promised that a better plan is coming — but so did Republicans throughout the Obama era, to little tangible result. Although the Trump administration has tweaked health policy in important ways, the Republican Party has largely left health care to the opposition, with some reports that Republicans in Congress have urged President Trump to play down the issue.
And yet looked at another way, the Democratic advantage on health care is not as strong as it might look.
First, there is the issue of eliminating private coverage. On the debate stage Wednesday night, Ms. Warren said she was for it, explicitly siding with Senator Bernie Sanders of Vermont, whose plan would wipe out nearly all private coverage in four years.
Ms. Warren’s reasoning — that insurers are an obstacle to good care — was delivered with her typical intensity and effectiveness. Yet surveys have found that support for single-payer drops when respondents are told that it would eliminate private coverage. When Senator Kamala Harris of California mounted a similar defense earlier in the year, she quickly moderated her position, saying that she was open to other options as well. (Though last night, she was among the candidates who responded in the affirmative to the idea that they would abolish private health insurance in favor of a government-run plan.) It’s not an accident that when President Barack Obama pitched his health care reform to the nation, he did so by repeatedly promising that those who like their plans could keep them.
The strongest pushback to Ms. Warren’s plan, meanwhile, came from former Maryland Representative John Delaney, who argued that a Sanders-style Medicare for All that paid current Medicare rates would result in the closure of hospitals. Mr. Delaney may have overstated the case by saying that all hospitals would close, but America’s hospitals would stand to lose billions of dollars.

Policy experts reportedly believe “some hospitals, especially struggling rural centers, would close virtually overnight” under such a system. If Mr. Sanders or Ms. Warren won the nomination, they would surely face accusations that they favored a system that would shutter struggling hospitals, reducing access for the rural poor, and closing centers of well-paying middle-class jobs throughout much of the country.
Not all of the candidates argued for single payer. Joe Biden made the case for building on Obamacare, which he helped usher into law. But even Mr. Biden’s argument was a tacit admission that the health law that was the signature policy of the previous administration is, at best, insufficient and incomplete.
And that gets to the mostly unspoken reason that health care has so dominated American politics, and the reason it played such a significant role in the first Democratic debate: It is the sense, shared by Republicans and Democrats alike, that Obamacare has failed or, at minimum, that it still needs considerable work.
This is not exactly a complete vindication of the law’s critics, but it does suggest that some of them were on to something, and that those who warned that Obamacare was a steppingstone to single payer might have had at least a partial point. Republicans, by failing to unite around a plan of their own, have given Democrats license to run with their wildest health policy dreams. But single payer is also a live issue at least in part because of the perception that Obamacare has not lived up to its initial promise of more affordable and accessible care.
In a 2009 speech about the law that would become Obamacare, Mr. Obama declared, “I am not the first president to take up this cause, but I am determined to be the last.” If nothing else, the first Democratic debates have made clear that he failed in this ambition, and that the lingering frustrations with the law he helped usher into being will be part of the reason.
https://www.nytimes.com/2019/06/28/opinion/democratic-debate-health-care-medicare-for-all.html

Where Is Kamala Harris on Medicare for All vs. Private Insurance? 

by Margot Sanger-Katz - NYT - June 28, 2019

On the debate stage Thursday, Senator Kamala Harris raised her hand, seemingly in support of a government insurance proposal that would eliminate employer insurance. On Friday, she said she had misunderstood the question.
The wording of the question left room for confusion, but Ms. Harris also has a history of making conflicting statements on the issue. In a CNN town hall in January, she said she’d favor eliminating all private health insurance. The next day, her campaign walked it back.
A single-payer health plan requires people with other forms of comprehensive health insurance to switch. That is a politically risky position. Some Democrats have hedged by backing more gradual, optional expansions of public coverage. Others have decided that they can persuade voters that the advantages outweigh the disruption. Ms. Harris, so far, hasn’t chosen either one.
Surveys show that most Americans — and a substantial majority of Democrats — back a single-payer system in which the government provides health insurance to everyone. But when surveys ask them if they’d still like that idea if they had to give up their insurance, many change their minds. Surveys asking people if they could keep their insurance under such a plan find many who say yes.

Senator Bernie Sanders of Vermont, who has supported a single-payer plan for decades and is the author of the Medicare for All Act, which Ms. Harris has co-sponsored, argues that support will increase as more voters learn about the benefits of his plan. Insurance under Medicare for all, he argues, will cover all doctors and hospitals, and include no co-payments or deductibles. He thinks such a plan has so many advantages that few Americans will remain attached to their current coverage once they understand it.
Some Democratic strategists look at the polls and worry about a backlash to the major disruptions such a plan would create. Candidates like Senator Michael Bennet of Colorado and the former vice president, Joe Biden, say they’d prefer a system in which people could choose to buy public insurance if they want — or keep the plan they have.
Medicare for all was once cast as a litmus test for the Democratic presidential field, but at this point most of the candidates favor this sort of optional approach, with a mix of public and private insurance.
Most candidates in the field endorsed such a plan in a recent New York Times survey, and in the debates’ less formal vote by show of hands.
Another solution might be government plans that cover some things, but allow people to buy private insurance for extras. In other countries with a universal public plan and private insurance, private insurance is there to fill holes in the government system. In Canada, private insurers pay for prescription drugs, which Canadian Medicare does not cover. In Britain, private insurance can get you extra services and the ability to jump the line for certain treatments. In the United States today, older people on Medicare buy supplemental insurance to help cover deductibles and co-payments charged by the government system.

Several candidates who have signed on to Medicare for all legislation suggested they would like to preserve “a role” for private insurance, and these vague statements could point to such a public-private system.
But such a policy stance may not reassure people who are reluctant to give up their current insurance arrangements. It could offer both the disruption of Medicare for all, and the inconvenience of private insurance, in one package.
In the debate Thursday, Lester Holt, the NBC anchor and one of the moderators, said: “Many people watching at home have health insurance through their employer. Who here would abolish their private health insurance in favorite of a government-run plan?” Ms. Harris later said she thought the “their” meant her, and not the people watching at home.
But in recent answers to a detailed New York Times survey on her health care policy preferences, Ms. Harris also positioned herself on the single-payer side of the line. When asked if she’d favor a plan that abolished private insurance, she said yes. When asked if she’d prefer a Medicare for all plan or an optional proposal, which she also endorsed, she said, “Medicare for all.”
“Medicare for All will extend health insurance to every single American, with no co-pays or premiums,” she wrote. “It will cover most procedures, as well as dental, vision and hearing aids, and will allow you to choose your doctor, without worrying about who’s in-network or not. We have to change a system that allows big insurance companies to put profit over people’s health.”
On Friday morning, she told the hosts of the MSNBC show “Morning Joe,” “No, I do not” support abolishing private insurance. “The question was would you give up private insurance for that option, and I said yes.”
It is hard to reconcile those positions.

https://www.nytimes.com/2019/06/28/upshot/kamala-harris-medicare-for-all-debate.html?

Majority Backs ‘Medicare for All’ Replacing Private Plans, if Preferred Providers Stay

Reduced support for single-payer overcome by assurance that Americans would not lose their doctor and hospital 

by Yusra Murad - Morning Consult - July 2, 2019

Democratic presidential candidate Sen. Bernie Sanders (I-Vt.) speaks to the media after the second night of the first Democratic presidential debate on June 27, 2019 in Miami. (Joe Raedle/Getty Images)

By July 2, 2019 at 12:01 am ET

• 55% of voters back a Medicare for All system that diminishes the role of private insurers if they retain access to their preferred providers.
  
• Independents are 14 points more likely to back the system when told losing their private plan would not mean losing their doctor (42% to 56%).
  

Though the dividing line between Democratic presidential candidates on “Medicare for All” concerns the elimination of the private insurance market, new Morning Consult data suggests that anxiety among voters may be misplaced fear about losing their providers rather than their private plans.
According to a Morning Consult/Politico survey conducted after the first Democratic presidential primary debates, support among voters for Medicare for All falls to 46 percent from 53 percent when respondents are told the government-run health system would diminish the role of private insurers — but rises back to 55 percent when voters learn that losing their private plans would still allow them to keep their preferred doctors and hospitals.

Between the forums last Wednesday and Thursday, only four of the 20 candidates onstage said they were in favor of abolishing private health insurance in favor of a government-run plan: New York City Mayor Bill de Blasio and Sens. Bernie Sanders (I-Vt.), Elizabeth Warren (Mass.) and Kamala Harris (Calif.). Harris later partially modified her position, stating she misheard the question and believes private plans should continue offering supplemental coverage alongside the federal system (as would be the case under Sanders’ Medicare for All plan).
“These numbers only affirm what the senator has said many times: people don’t like insurance companies, they like their doctors and their hospitals,” Sanders’ campaign said of the data in an email to Morning Consult. “Despite what the pharmaceutical and insurance industries will tell you, Medicare for All is the only proposal that gives Americans the freedom to control their own futures — change jobs, start a family, start a business  — and keep their doctor.”
Several polls have demonstrated that support for Medicare for All plummets when Americans learn the system would replace employer-sponsored coverage with one sweeping plan, forcing single-payer supporters to go on the defensive to alleviate concerns from voters. But as candidates attempt to persuade voters that Medicare for All would not require diminishing the role of private insurers — further adding to confusion among the electorate about what exactly the system would entail — the new data suggests that the consequences of that argument can be mitigated by clarifying that losing private insurers would not affect access to preferred providers.

The June 29-July 1 survey of 1,472 voters found that explanation to be especially effective in quelling skepticism among Democrats and independents. Among independents, 56 percent back a Medicare for All system that nixes the private market but allows people to keep their doctors — a 14-point increase over the share that only hears about the diminished role of private insurers. The poll had a margin of error of 3 percentage points.
Republicans, who have not yet forgotten former President Barack Obama’s promise with respect to the Affordable Care Act that “if you like your health care plan, you can keep it,” were mostly unmoved by the addendum.
Private insurance companies have much to lose from the implementation of Medicare for All, leading opposition efforts on Capitol Hill and across the country alongside Republicans, who have decried single-payer as a socialist takeover of health care. Few candidates have been frank in admitting the Medicare for All bills in the House and Senate would phase out private insurers over a transition period of two or four years, respectively. Other presidential hopefuls, such as Sen. Kirsten Gillibrand (N.Y.) and former Texas Rep. Beto O’Rourke, have offered broad statements in support of universal health care while insisting they would not lessen the role of insurers in the U.S. health care system.
Previous Morning Consult polling has also indicated Americans who are against Medicare for All on the grounds that it would reduce the role of insurance companies may be inadvertently conflating their payers and providers. Among adults who said they opposed the system, 62 percent said they are more likely to support the plan if they could keep their doctors and hospitals.

https://morningconsult.com/2019/07/02/majority-backs-medicare-for-all-replacing-private-plans-if-preferred-providers-stay/ 

American caravan arrives in Canadian 'birthplace of insulin' for cheaper medicine

by Thomson Reuters - CBC News - June 28, 2019

A self-declared "caravan" of Americans bused across the Canada-U.S. border on Saturday, seeking affordable prices for insulin and raising awareness of "the insulin price crisis" in the United States.
The group called Caravan to Canada started the journey from Minneapolis, Minn., on Friday, and stopped in London, Ont., on Saturday to purchase life-saving type 1 diabetes medication at a pharmacy.
The caravan numbers approximately 20 people, according to Nicole Smith-Holt, a member of the group. Smith-Holt said her 26-year-old son died in June 2017 because he was forced to ration insulin due to the high cost. Type 1 diabetes often develops in childhood or early adulthood.
This is Smith-Holt's second time on the caravan. Caravan to Canada trekked over the border in May for the same reasons, with a group smaller than the one this week, Holt-Smith said. She said Americans have gone to countries like Mexico and Canada for more affordable medications in the past and continue to do so.
CBC News reported in May that Canadian pharmacists have seen a "quiet resurgence" in Americans coming to Canada  looking for cheaper pharmaceuticals.
Insulin prices in the United States nearly doubled to an average annual cost of $5,705 US in 2016 from $2,864 in 2012, according to a study in January.

On the way to Banting House

Quinn Nystrom, a leader of T1International's Minnesota chapter, said in May that the price in the U.S. of insulin per vial was $320 US, while in Canada the same medication under a different name was $30.
T1International, a non-profit that advocates for increased access to type 1 diabetes medication, has described the situation in U.S. as an insulin crisis.
"We know that many people couldn't make this trip because they cannot afford the costs associated with travelling to another country to buy insulin there," said Elizabeth Pfiester, the executive director of T1International in a press release.
An itinerary states the caravan will stop at the Banting House in London later in the day.

Sir Frederick Banting, seen here in a 1921 photograph, is one of the co-discoverers of insulin with Charles Best, then a student at University of Toronto. (Sir Frederick Banting House)

Banting House is where Canadian physician and scientist Frederick Banting, who discovered insulin with fellow Nobel laureate Charles Best, lived from 1920 to 1921, and is called the "birthplace of insulin," according to the Banting House website. Much of the experimentation that led to effective treatment took place at University of Toronto and the Banting Institute is in Toronto.
Smith-Holt said she hopes for long-term solutions in the United States like price caps, anti-gouging laws, patent reform and transparency from pharmaceutical companies.

https://www.cbc.ca/news/canada/london/insulin-prices-united-states-canada-caravan-1.5195399

Aligning House And Senate Single-Payer Bills: Removing Medicare's Profiteering Incentives Is Key

by Steffie Woolhandler and David Himmeltein - Health Affairs - November 19, 2018

Single-payer reform is in the news—and in the U.S. House and Senate. One hundred twenty-three Congresspeople have signed on as co-sponsors of H.R. 676, the single-payer legislation in House of Representatives, and 16 Senators have formally endorsed S.1804, the Senate version. (Disclosure: H.R. 676 was closely modeled on the Physicians for a National Health Program reform proposal published in JAMA, for which we served as lead authors).
While both bills would cover all Americans under a single, tax-funded insurance program, they prescribe different provider payment strategies. The Senate version largely adopts Medicare's current payment mechanisms; the House bill's is modeled on Canada's single-payer program, also called "Medicare," which pays hospitals global budgets (much as a fire department is paid in the U.S.) and sharply constrains opportunities for investor-owned care.
These differences haven't attracted much attention from politicians or the press, and few patients are aware of, or deeply concerned about them. That's not surprising, since both bills address the lay public's most pressing payment-related concern: they would drastically shrink (S.1804) or completely eliminate (H.R. 676) out-of-pocket payments for needed care.
But these divergent payment strategies would create very different financial incentives for providers, shaping the culture of medicine and the financial viability of a single-payer reform. The Senate version would, like Medicare, pay hospitals and other institutional providers on a per-patient basis, intermixing payments for current operating expenses with funding for future capital investments and profits. As at present, hospitals' success, and even survival, would depend on generating profits ("surpluses" in non-profit facilities). Hospitals with a favorable bottom line could invest and add new buildings and programs, while unprofitable ones couldn't modernize or expand, risking a downward spiral toward takeover or closure.
It's this profit imperative that drives hospitals' financial gaming, e.g. upcoding, and concentration on the most lucrative services, such as elective cardiac and orthopedic services, rather than money losers like mental health. This payment mechanism (and S.1804 as a whole) also leaves the door open to investor-owned providers.
In contrast, the House bill would abolish per-patient billing by hospitals and other institutions, and its global budget payments would cover only operating costs; hospitals would be prohibited from retaining surpluses, and capital investments would be funded through separate government grants. The bill would also explicitly proscribe payments to investor-owned facilities, and it calls for their conversion to non-profit status financed by issuing bonds.
Expanding and improving coverage, as both S.1804 and H.R. 676 would do, is expected to increase care utilization and hence clinical costs. Yet most analysts foresee savings on billing and administration (as well as on prescription drugs prices) that would offset these increases. Both bills would replace the current welter of private plans—with average overhead of about 12 percent of premiums—with a single public insurer whose overhead would likely be similar to the traditional Medicare program's 2 percent, or the 1.6 percent in Canadian Medicare (National Health Expenditure Trends, 1975 to 2017: Data Tables — Series A).
But insurance overhead accounts for only 44 percent of the administrative savings that could be realized under a single-payer program; the rest comes from streamlining providers' administrative work. For instance, U.S. hospitals' administrative costs average 25.3 percent of their total revenues, versus only 12 percent in single-payer systems like Canada's and Scotland's that pay global operating budgets and minimize rewards for financial gaming.
Medicare's payment approach requires hospitals to bill for and justify each hospitalization, a requirement that persists in value-based payment schemes like ACOs and would continue under S.1804. Hence, hospitals would have to maintain much of their current wasteful billing, documentation, and internal cost-tracking systems. Retaining the profit imperative would also continue to reward hospitals for financial gaming and tailoring services to profitability, driving up both administrative costs and wasteful spending on low-value care.
Instead of bundled payment arrangements tied to individual patients, the House version would substitute an institution-wide bundled payment, i.e., a global budget covering all operating costs. As noted above, that approach has streamlined hospital administration in other nations, which have been more effective than the United States at restraining overall costs. In contrast, ACOs have increased providers' administrative costs by about $200 per patient annually, and have generated trivial or no savings after accounting for Medicare's "shared savings" bonus payments. Similarly, Medicare's (and other payers') pay-for-performance initiatives impose substantial administrative costs on providers, with no evidence that they've improved patients' outcomes in any setting.
In sum, the financial viability of a single-payer reform turns on cutting administrative costs and minimizing incentives for financial gaming. Maintaining Medicare's current payment strategies, as under S.1804, would be substantially costlier than adopting the non-profit global-budgeting strategy used in several other nations.
Differences in payment strategies also have implications for the work lives of doctors and other clinical personnel. Medicare's turn to ACOs effectively forces providers to become insurers who bear the risk of their patients' medical expenses, even those incurred in other venues. This strategy virtually banished small independent providers, triggering a wave of mergers and acquisitions. Community hospitals have been gobbled up, and a rapidly growing share of doctors have become employees.
The profit imperative imposed on hospitals and physician practices by Medicare's payment incentives filters down to doctors. It manifests as morale-sapping productivity pressures; redundant documentation requirements; time wasted on mandatory upcoding classes; and the sense that clinical priorities have become subservient to financial ones. The length of doctors' notes in EPIC's electronic health record—larded with clinically useless templated and copied material, and four times as long in the U.S. as in other nations—gives one indication of how payment rules translate into burnout.
The Senate's version risks maintaining these ACO-driven incentives, and even risks the reemergence of private insurance under the guise of vertically integrated, risk-bearing corporate ACOs.
The House single-payer bill envisions a buyout of the investor-owned facilities needed to provide care under the single-payer system, while the Senate version would leave them in current hands.
Proponents of the House approach acknowledge that many non-profit health care organizations have drifted far from their charitable roots. However, they cite evidence that for-profit providers (including hospitals, dialysis centers, nursing homes, home care agencies, and hospices) provide inferior care at inflated prices (see, for instance here, here, here, here and here) and are more likely to bend care to profitability (see here, here, here and here). For-profit hospitals spend less on nurses and other clinical aspects of care, but more on administration and financial management; for-profit chains have often been cited for questionable business practices and have been repeatedly implicated in large scale fraud (see here, here, here and here).
According to CMS, for-profit nursing homes are cited for quality deficiencies 28 percent more often than non-profits, and for deficiencies that place residents in immediate jeopardy 53 percent more frequently. Investor-owned home care agencies cost Medicare $752 more per patient than non-profit agencies, while providing worse care.
Yet even some who would prefer to exclude investor-owned facilities from a single-payer system worry about the cost of a buyout. In conversations with Congressional aides, some have suggested that these costs could amount to $1 trillion or more, although none could cite a source for that figure. While it's not clear exactly how to value the assets of investor-owned medical facilities, estimates of their current capital assets and of their stock market valuations provide some guidance.
In the detailed cost reports filed with Medicare covering fiscal year 2016 (the most recent year for which virtually all reports are available), all for-profit hospitals taken together reported total capital assets of $97.845 billion at the start of the year, and additional purchases totaling $7.453 billion (Himmelstein & Woolhandler, unpublished analysis of hospital cost reports). So the total capital stock of all for-profit hospitals - including not just acute care hospitals, but most other inpatient facilities besides stand-alone nursing homes - totaled $105.298 billion. (The comparable figure for non-profits is $718.628 billion).
Since most investor-owned providers also carry debt, it's not surprising that the capital asset figures are considerably higher than the stock market value of the firms that own the facilities. As indicated in Exhibit 1, the market valuation of the five publicly-traded firms that account for the vast majority of for-profit hospitals totals $50.071 billion. While data on the market value of the (smaller) privately held for-profit hospital chains is not available, the value of the larger chains, and past sale prices for three of the privately-held firms, suggests that they'd add only several billion to the total.

Exhibit 1: Market Value Of Investor-Owned Health Care Providers

 
Notes for Exhibit: Figures for market capitalization for firms that are included in the Fortune 500 were taken from Fortune June 1, 2018.  Other figures are from Google Finance and other online sources, searched October 26, 2018.
* Privately-held firm, no market capitalization or recent sale price data available
** Figures include value of dialysis supply business as well as health service delivery.  Fresenius figure is adjusted for share of business in U.S.
*** Figures for some nursing firms include value of senior living communities
Similarly, as Exhibit 1 shows, the total value of shares in publicly traded nursing home firms, rehab, dialysis, and home care and hospice providers is relatively modest: less than $50 billion. And these valuations (which fluctuate from day-to-day) include aspects of the businesses that would not be included in a buyout, e.g. the value of real estate devoted to senior living communities, or the roughly 15 percent of DaVita's business that's unrelated to dialysis and the 20 percent of Fresenius' revenues attributable to sales of products such as dialysis supplies.
Overall, the fair market value of investor-owned facilities covered by a buyout, whether assessed by capital stock or stock prices, seems unlikely to exceed $150 billion. Purchasing these assets using Treasury Bill financing over 15 years at the current interest rate of 3 percent would cost about $12.75 billion annually, equivalent to about 1 percent of annual hospital costs. Moreover, even in the short term, some or all of these costs would be offset by savings on profits, which totaled more than $6 billion in 2017 for just three of these firms (HCA, DaVita and Fresenius).
Bottom line: A buyout of investor-owned facilities is affordable. Indeed, it might well lower costs.
In the short run, the divergence between the House and Senate versions of single-payer reform is of little consequence. No bill will be enacted under the current administration. Yet with support for single payer blossoming among Democratic leaders and the public, the prospect of legislative action is increasing, and with it the push for convergence. Indeed, Pramila Jayapal, the leader of the House Single-Payer Caucus, has indicated her intent to move the two bills closer together.
In aligning the bills, House members should, in our view, adopt some aspects of the Senate's bill, notably its repeal of the Hyde Amendment that forbids using federal funds for abortion, as well as its greater specificity. But Senators should adopt the House bill's payment strategies and commitment to non-profit ownership of health care providers. 

https://www.healthaffairs.org/do/10.1377/hblog20181116.732860/full/