Arguing with Zombies review: Paul Krugman trumps the Republicans
The Nobel-winning economist and New York Times columnist is at the
top of his game in eviscerating those who have dragged America down
by Charles Kaiser - The Guardian - May 3, 2020
The New York Times columnist Paul Krugman has four essential rules for successful punditry:
Stay with the easy stuff
Write in English
Be honest about dishonesty
Don’t be afraid to talk about motives
Those maxims have consistently made Krugman the most intelligent and
the most useful New York Times pundit, at least since Frank Rich wrote
his final must-read column 11 years ago. A new collection of Krugman’s
pieces, therefore, is a timely reminder that actual knowledge and
ordinary common sense are two of the rarest qualities in mainstream
journalism today.
Krugman’s enemies are the “zombie ideas” of his book’s title,
especially the belief that budget deficits are always bad and the notion
that tax cuts for the rich can ever benefit anyone other than the
plutocrats who never stop pleading for them.
The same tired arguments in favor of coddling the rich have been
rolled out over and over again, by Republican presidents from Ronald
Reagan to Donald Trump, even though there has never been a shred of serious evidence to support them.
These relentless efforts over five decades culminated in the Trump tax cut, memorably described by the political consultant Rick Wilson
as a masterwork of “gigantic government giveaways, unfunded spending,
massive debt and deficits, and a catalogue of crony capitalist
freebies”.
Wilson also identified the billionaires’ effect on the nation’s
capital. Washington, he wrote, has become “the drug-resistant syphilis
of political climates, largely impervious to treatment and highly
contagious”.
Krugman’s columns act like a steady stream of antibiotics, aimed at
restoring the importance of the economic sciences that have been so
successfully displaced by brain-dead Republican ideology.
Very few political columns are worth reading 12 months after they are
written – the New York Times grandee James Reston accurately titled one
of his collections Sketches in the Sand. But Krugman’s book proves that
he, a Nobel-prize winning economist, shares two rare qualities with
George Orwell, the novelist who also wrote much of the best journalism
of the 20th century: deep intelligence and genuine prescience.
Krugman is at his Orwellian best here: “When you’re confronting
bad-faith arguments, the public should be informed not just these
arguments are wrong, but they they are in fact being made in bad faith.”
It’s “important to point out that the people who predicted runaway
inflation from the Fed’s bond buying were wrong. But it’s also important
to point out that none of them have been willing to admit that they
were wrong.”
Krugman also writes that “even asking the right questions like ‘what
is happening to income inequality’” will spur quite a few conservatives
to “denounce you as un-American”. And it’s worse for climate scientists,
who face persecution for speaking the truth about our continued
dependence on fossil fuels, or social scientists studying the causes of
gun violence: “From 1996 to 2017 the Centers for Disease Control were
literally forbidden to fund research into firearm injuries and deaths.”
The history of the last half-century is mostly about how the
unbridled greed of the top 1% has perverted American democracy so
successfully, it has become almost impossible to implement rational
policies that benefit a majority of Americans.
To Krugman, an “interlocking network of media organizations and think
tanks that serves the interests of rightwing billionaires” has
“effectively taken over the GOP” and “movement ‘conservatism’ is what
keeps zombie ideas, like belief in the magic of tax cuts, alive.
“It’s not just that Trump has assembled an administration of the
worst and the dimmest. The truth is that the modern GOP doesn’t want to
hear from serious economists, whatever their politics. It prefers
charlatans and cranks, who are its kind of people.”
Even now, as the incompetent kleptocrats who have filled up the White
House and every federal agency confront the greatest worldwide health
emergency of modern times, they have maintained their laser-like focus
on the interests of the rich. As the Guardian has reported,
“Millionaires and billionaires are set to reap more than 80% of the
benefits from a change to the tax law Republicans put in the coronavirus
economic relief package … the change will allow some of the nation’s
wealthiest to avoid nearly $82bn of tax liability in 2020.”
And as the great labor reporter Steven Greenhouse pointed out this week,
with Trump’s latest executive order to keep meatpacking plants open
regardless of the consequences to their employees, the president is
literally “marching many meatpacking workers off to slaughter”.
Never before in modern American history has the plutocracy so
blatantly embraced the idea that profits matter much more than people –
especially when the idiotic reopening of the economy weeks before health
experts say it’s safe will clearly kill more poor people than anyone else.
When I was 15, I acted as the translator for my uncle Jerry’s family
on a tour of the grand chateaux of the Loire Valley. As we traipsed
through one spectacular example of conspicuous consumption after
another, my deeply progressive uncle kept repeating the same question:
“What took them so long to start the revolution?”
If our present calamity is finally enough to force the
climate-change-denying, poor-people-hating Republican party from the
White House and the Senate, one can only hope the popular imagination
will be stirred as it was in Paris in 1793.
Pamela Hartzband, M.D. and Jerome Groopman, M.D. - New England Journal of Medicine - May 1, 2020
Before the onset of the Covid-19
pandemic, each day seemed to bring another headline about the crisis of
physician burnout. The issue had been simmering for years and was
brought to a boil by mounting changes in the health care system, most
prominently the widespread implementation of the electronic health
record (EHR) and performance metrics.1
Initially, the prevailing attitude was that burnout is a physician
problem and that those who can’t adapt to the new environment need to
get with the program or leave. Some dismissed the problem as a
generation of “dinosaur” doctors whining and pining for an inefficient,
low-tech past. But recently, it has become clear that millennials,
residents, and even medical students are showing signs of burnout. The
unintended consequences of radical alterations in the health care system
that were supposed to make physicians more efficient and productive,
and thus more satisfied, have made them profoundly alienated and
disillusioned. The problem has become even more urgent with the
realization that it’s costing the health care system approximately $4.6
billion a year.2
Solutions
have largely targeted the doctor, proposing exercise classes and
relaxation techniques, snacks and social hours for decompressing,
greater access to child care, hobbies to enrich free time, and ways to
increase efficiency and maximize productivity. There is scant evidence
that any of these measures have had a meaningful impact, as shown by a
recent meta-analysis of 19 controlled studies evaluating a total of more
than 1500 physicians.3
These data lead to the inescapable conclusion that currently proposed
solutions do not address the underlying problem: a profound lack of
alignment between caregivers’ values and the reconfigured health care
system. A largely neglected field of organizational psychology provides
an explanation and a roadmap for ameliorating physician burnout.
Seminal work by Gagné and Deci examined motivation in the workplace.4
The researchers classified motivation as intrinsic or extrinsic: people
may perform an activity because they find it interesting and derive
spontaneous satisfaction from the activity itself (intrinsic
motivation); or they may receive a tangible external reward, so that
satisfaction comes not from the activity itself but from that reward
(extrinsic motivation). One might imagine that intrinsic and extrinsic
motivators would have additive or even synergistic effects. But Gagné
and Deci showed that tangible extrinsic motivators, such as monetary
rewards, can paradoxically undermine intrinsic motivation. Such
unexpected effects occur particularly among professionals who undertake
complex tasks requiring cognitive flexibility, creativity, and problem
solving.
Medicine is in many ways unique. Doctors, nurses, and
other health care professionals have traditionally viewed their work as a
calling. They tend to enter their field with a high level of altruism
coupled with a strong interest in human biology, focused on caring for
the ill. These traits and goals lead to considerable intrinsic
motivation. In a misguided attempt to improve the medical system, health
care reformers put into place various positive and negative extrinsic
motivators, without realizing that they would actually erode and destroy
intrinsic motivation, eventually leading to “amotivation” — in other
words, burnout.
Reformers are perplexed that monetary incentives
haven’t worked to prevent or remedy burnout. Using a monetary reward as a
central motivation strategy seems practical and appealing. However, in a
recent survey of more than 15,000 doctors in 29 specialties (Medscape
National Physician Burnout and Suicide Report 2020), half the doctors
said they would give up at least $20,000 in annual income in order to
reduce their work hours; these doctors included millennials, who are
among the lowest earners. It’s important to emphasize that money in and
of itself is not toxic; Gagné and Deci observed that an increase in
yearly salary or a bonus does not diminish intrinsic motivation. But
bringing money to the fore in each individual patient interaction — by
translating physicians’ work into relative value units, for example —
does.
Gagné and Deci posit that there are three pillars that
support professionals’ intrinsic motivation and psychological
well-being: autonomy, competence, and relatedness.3 All three have been stripped away as a direct result of the restructuring of the health care system.1
Autonomy,
according to Gagné and Deci, means having the right to act with a sense
of volition and having the experience of choice. Physicians now endure a
profound lack of control over their time and even language. The amount
of time we spend with a patient, what is discussed (even to the point of
uniform scripts), and how a visit is documented are all frequently
mandated. We are further controlled by surveillance in the form of time
and motion studies and timing of our use of the EHR.
Competence
was once viewed as having a deep fund of medical knowledge and
exercising clinical judgment appropriately with each patient. Under
recent health care reforms, it has been redefined as compliance with
various metrics, many of which are not evidence-based. Competence has
also become a matter of checking off boxes in the EHR and satisfying
insurers’ demands by quickly placing a note in the record for billing
purposes, even if it’s incomplete or erroneous. In defense, many doctors
now add a disclaimer that the note has not been proofread and to
“disregard any errors.”
Relatedness is the psychological feeling
that one belongs, has interpersonal attachments, and is connected to the
social organization. Doctors want to give patients the time and support
they need, and they want the system to value and recognize their
efforts to provide this kind of care. While much lip service is given to
“patient-centered care,” many doctors feel that the system is
increasingly driven by money and metrics, with rewards for professionals
who embrace these priorities.
Medicine’s daily tasks have become
Sisyphean. Physicians recognize that it’s impossible to satisfy the
current system’s demands. If you surrender, the joy of engaging with
your patients is diminished and ultimately lost. If you resist, you
incur the system’s wrath. Doctors are finally expressing the pain they
feel. Emily Silverman, a hospitalist at the University of California,
San Francisco, recently bemoaned in the New York Times “the
relentless reminders of tasks we haven’t completed, supplications to
correct our documentation for billers, and daily, jaundiced reminders:
You are currently deficient.”
Burnout is toxic for patients as
well as physicians, because it’s associated with loss of empathy,
impaired job performance, and increases in medical mistakes.5
Family and friendships also suffer as the EHR’s demands invade doctors’
homes and consume the time once enjoyed in vital relationships,
worsening emotional exhaustion.
The problem of burnout will not be
solved without addressing the issues of autonomy, competence, and
relatedness. Evidence from the meta-analysis of controlled interventions
supports the restoration of autonomy; giving doctors flexibility in
their schedule to allow for individual styles of practice and patient
interaction was one of the few system solutions that reduced burnout.3
Flexibility in scheduling recognizes that both patients and doctors are
individuals, and some interactions simply take longer than others. The
EHR, initially lauded for its potential as a repository of patient
information, has become a tyrannical, time-consuming billing tool; it
must be reconfigured to work for physicians rather than forcing
physicians to work for it.
Competency can be restored by purging
the system of meaningless metrics while maintaining a core of
evidence-based measures, allowing for clinical judgment, and honoring
individual patient preferences. Relatedness should be authentic,
aligning the system’s values with those of physicians, nurses, and other
health care professionals who chose their careers out of altruism.
Restoring these three pillars will support the return of intrinsic
motivation.
With the Covid-19 pandemic, medicine is at a crisis
point. Health care professionals are responding with an astounding
display of selflessness, caring for patients despite the risk of
profound personal harm. Our efforts are recognized and applauded. During
this interlude filled with uncertainty, there has been a sense of
altruism and urgency that has unexpectedly catalyzed the restoration of
some elements of autonomy, competency, and relatedness. Indeed, the
whole medical system, including hospital administrators and insurers,
among others, has rallied to support the caregivers. But will these
positive changes be sustained? Tectonic shifts are at work as hospitals
and clinics suffer grave financial losses and the workforce is
diminished by illness and exhaustion. As the current crisis ultimately
abates, we need to remember the lesson that the system can be reset. It
is time to evaluate what has worked and what hasn’t in health care
reform. We must not return to the former status quo. https://www.nejm.org/doi/full/10.1056/NEJMp2003149?query=RP
The unlikely alliance trying to rescue workplace health insurance
As millions lose employer health plans, powerful Washington groups are uniting behind a bailout of the popular coverage.
Big businesses and powerful
Democrats are aligning around a proposal to bail out employer health
plans in the wake of staggering losses to the insurance industry, as
some worry that a surge in uninsured Americans could give new life to a
stalled push for “Medicare for All.”
The business and labor interests, who have strong economic motives
to keep the current system of employer-based care, are rallying behind a
Democratic effort to subsidize temporary extensions of newly unemployed
Americans’ workplace health plans in Congress’ next coronavirus rescue
package.
But to some progressives who cheered Bernie Sanders' (I-Vt.)
Medicare for All plan, the crisis has exposed what they see as the folly
of tying employment to health coverage. Sanders, who's advocating for
an emergency version of his health plan during the pandemic, ripped the
idea of propping up an expensive employer system in a POLITICO op-ed Tuesday.
"Not only
would health insurance corporations make massive profits off the
plan—profits that come at the cost of the American taxpayers—but it
would still leave tens of millions uninsured or underinsured," the
former Democratic presidential candidate wrote. "And during this
pandemic, a lack of insurance means more Covid-19 transmissions and more
deaths."
America’s health care
system since World War II has relied on the increasingly costly employer
insurance market. But with 26 million people rapidly losing their jobs
amid a massive health crisis, the idea of tying coverage to the
workplace is facing its biggest stress test yet.
Employers, health care groups and unions badly want the employer system
to emerge from the health crisis unscathed, believing it would ward off
any new expansion of government health care. Joe Biden’s rise to
becoming the presumptive Democratic nominee was a relief to the health
care industry, which has spent the past two years attacking Medicare for
All. Health care groups also oppose other more incremental government
expansions, like a public option Biden and other moderate Democrats
support.
“This crisis will be
over — not soon enough, but it will be over — and we need to
fundamentally keep that highway back to jobs and job-provided health
care open,” said Ilyse Schuman, senior vice president of health policy
for the American Benefits Council, which represents major employers.
“That’s what Congress needs to do now, and employer-sponsored insurance
plays a big role in that.”
Experts
estimate the job-based insurance market has likely already lost
millions of customers as unemployment skyrockets, and a growing number
of insurers hoping to retain business are offering grace periods on
premium payments. Few people losing their jobs sign up for temporary
workplace insurance, known as COBRA plans, unless they desperately need
the coverage. And it's both complicated and extremely costly, since it
comes without employer subsidies that typically cover the lion’s share
of monthly premiums.
Newly
unemployed people losing health insurance can often find cheaper or even
free coverage through the Obamacare insurance markets or Medicaid.
However, President Donald Trump’s refusal to broadly reopen the
Obamacare markets or make enrollment easier for those eligible may limit the safety net’s reach.
Many of the poor won't be eligible for Medicaid in the remaining 14
states that have not expanded the programs under Obamacare.
While the health industry and Democrats still want to bolster
Obamacare, an unusual bloc is pressuring Congress to fully subsidize
workplace premiums for the uninsured. Corporations would benefit because
the employer-based system supplies a big tax break for benefits they
can use as a recruiting tool. Unions would keep the generous coverage
they have negotiated with corporations. And hospitals and doctors could
maintain the big payouts from private insurance, which are far higher
than the Medicare and Medicaid rates paid by government.
Such an idea could hit the political sweet spot on Capitol Hill.
Workplace plans, which covered an estimated 160 million Americans before
the pandemic, remain popular. Democratic leaders in Congress know
Republicans have little appetite for broadly expanding government
coverage, and Biden has endorsed temporarily subsidizing workplace
plans. Republicans, despite railing against insurer “bailouts” in
Obamacare for years, are friendlier to employer-based insurance and may
be more receptive to a deal that could prevent millions of people
joining the Medicaid rolls.
The
health care industry is spooked by a widely circulated projection that
between 12 million and 35 million people could lose their employer
health plan in the economic fallout from coronavirus. The same analysis
from consulting group Health Management Associates predicts the
uninsured ranks could swell from 28 million to 40 million people, while
Medicaid rolls in expansion states would also grow. That prospect
worries the hospital industry, which endorsed COBRA aid on Tuesday,
since the safety net program typically pays much less than Medicare.
Meanwhile, the health care industry is also trying to win back
Americans’ trust about the affordability of the system, just months
after hospitals and physician groups helped derail an effort to ban
exorbitant “surprise” medical bills. Big insurance companies are waiving
deductibles and copays for their commercial plans and the Trump
administration is offering Medicare payments to hospitals so they don’t
charge uninsured coronavirus patients.
Industry experts downplay the idea the pandemic poses an existential
threat to employer insurance, noting that once the economy rebounds the
same dynamics that have made the market attractive will remain
unchanged.
Still,
the market has already taken a hit. Additionally the yearslong trend of
small businesses dropping employee coverage will likely accelerate,
either because they will have shuttered or need to cut costs.
Ultimately, the future of employer-based insurance will be steered by
large corporations that are the backbone of the market, said Linda
Blumberg of the Urban Institute. The uncertain prospects for recovery
from this crisis, however, remain a wild card.
“I think a lot remains to be seen with regard to how strongly the labor market bounces back and how long it takes,” she said.
Unions, major insurers, hospitals and the consumer advocacy group
Families USA have banded together through a group called the Alliance to
Fight for Health Care, and are lobbying Congress to subsidize COBRA
through the next stimulus package.
Supporters said COBRA aid would provide a backstop to hospitals and
physicians, whose finances have been hurt by the cancellation of
elective procedures during the crisis. Congress has already approved
$175 billion to health care providers with few strings attached.
“Hospitals and providers are seeing tremendous expense and increase in
uncompensated care and uninsured individuals coming in, while also
seeing drops in elective procedures, so I think it’s money well spent in
protecting employees in a time of crisis,” said Katie Mahoney, vice
president of health policy for the U.S. Chamber of Commerce.
House Speaker Nancy Pelosi first pitched COBRA subsidies a month ago in a proposed alternative to the $2.2 trillion CARES Act that was ultimately approved by Congress. House Education and Labor Chairman Bobby Scott
(D-Va.) and Rep. Debbie Dingell (D-Mich.) earlier this month unveiled
standalone legislation fully subsidizing employer premiums for laid-off
or furloughed workers.
Support from unions puts pressure on progressive Democrats, the driving force behind Medicare for All, to back the policy.
Unite Here, representing mostly service workers, said Congress must
subsidize workplace plans. The union’s international president, D.
Taylor, estimates 95 percent of its members are unemployed during the
crisis.
“The health care crisis of a lifetime requires full emergency health
care coverage for those millions of hardworking Americans who, through
no fault of their own, have become unemployed," Taylor said.
But the effort has raised eyebrows among some liberal policy
experts, who say Democrats are overlooking the health care law they’ve
spent the past 10 years defending. They said Democrats should be trying
to expand that safety net at a time when health coverage independent
from a workplace is more important than ever.
The law’s individual market plans are expensive but are still
ultimately cheaper for the government to subsidize than employer
coverage. Medicaid plans, which offer full coverage for lower-income
adults in expansion states, are cheaper still. And analysts question
whether the subsidies would be money well spent when they only buy
temporary certainty for workers and their families, who may ultimately
have to turn to the Affordable Care Act if the economy is slow to
recover.
“At a time when you don’t know if people are going back to work, or
where they’ll go back to work, getting them better ACA coverage would be
more expedient,” said Arielle Kane, director of health policy at the
Progressive Policy Institute.
Moreover, experts note, COBRA subsidies come with a huge price tag
and ultimately help the middle- and higher-income people, rather than
lower-income people more likely to work retail and service jobs affected
by shutdowns.
“Almost no matter the employment outlook or time horizon, COBRA
subsidies are unlikely to be the most cost-effective way of expanding
coverage or relieving financial hardship,” said Matt Fiedler, former
chief economist of the Council of Economic Advisers under the Obama
administration. “They’re just not targeted on the right people.”
Congress subsidized COBRA in the last recession, before Obamacare
was passed. The aid had limited reach — only about one-third of those
eligible for subsidies signed up for coverage, according to a 2015 Labor
Department review. Congress at the time agreed to a 65 percent premium
subsidy. This time, groups are pushing to cover the entire amount.
Tom Leibfried, a health care lobbyist for AFL-CIO, acknowledged some
progressives would rather expand government coverage through the
crisis, but he stressed that it would be easier to work within the
existing system to deliver faster relief.
“So as happened in 2009, during the Great Recession, it’s just more
practical to turn to existing institutions and use those to make sure
people get the care they need and don’t face financial hardship,” he
said.
As the coronavirus continues to
spread, and the United States climbs closer to 1 million cases and
nearly 60,000 deaths, we face an unprecedented economic and health care
crisis that demands an unprecedented response. Whilewe work
toward an economic solution that keeps people on the payroll, Washington
is also in the midst of a crucial argument over how to help cover the
costs of testing, treatment and all other essential care for the
millions of people who are now uninsured or soon will be as the country
faces record levels of job loss. This pandemic makes even more clear
that we are all only as safe as the least-insured in our country.
Last week, the White House said it would give an unspecified amount
of federal aid directly to hospitals to cover the costs of treating
uninsured Covid-19 patients, but details have not been released, and the
proposal leaves out all non-Covid-19—but still crucial—medical care.
The week before, a handful of Democrats proposed spending hundreds of
billions of dollars on expanding subsidies for COBRA—the program that
allows those who have lost their jobs to continue, on a temporary basis,
paying out-of-pocket for the health insurance coverage they received
from their previous employer.
But there’s another, better way to guarantee that everyone in America
gets all the health care they need, without cost, for the duration of
the pandemic: Empower Medicare to pay all of the health care costs for
the uninsured, as well as all out-of-pocket expenses for those with
existing public or private insurance, for as long as this pandemic
continues. Our Health Care Emergency Guarantee Act is more comprehensive than Trump’s vague proposal and less expensive than the Democrats’ COBRA expansion.
Let’s be
clear: Even before this crisis began, 87 million Americans were
uninsured or underinsured—struggling to get to a doctor when they needed
to. Now the situation is much worse.
There
is no doubt that the health care crisis we are facing right now is an
emergency. Already, an estimated 9.2 million workers have lost their
employer-sponsored insurance, and as many as 35 million people might
lose coverage by the end of the crisis. Meanwhile, the cost of hospital
treatment for the coronavirus amounts to tens of thousands of dollars,
and patients struggling with the disease are desperately worried that
they cannot afford treatment or might go bankrupt if they get it. To
make matters worse, some of the communities hit hardest by the
coronavirus, such as the undocumented, largely do not have any health
insurance coverage at all.
Yet,
unbelievably, in the midst of this horrific pandemic, Republicans in
Congress have only continued their cruel and single-minded focus on
repealing the Affordable Care Act. Further, Republican governors, like
Greg Abbott in Texas, continue to fight against Medicaid expansion,
leaving many of the most vulnerable people in their states desperate and
sick.
While almost all Democrats
understand the severity of the crisis and the need to act, too many of
them are proposing a totally inadequate response that would simply lock
in place the dysfunction and waste of our current health care system.
Subsidizing
COBRA, as they have suggested, would be both expensive and ineffective:
Not only would health insurance corporations make massive profits off
the plan—profits that come at the cost of the American taxpayer—but it
would still leave tens of millions uninsured or underinsured. And during
this pandemic, a lack of insurance means more Covid-19 transmissions
and more deaths.
Expanding
COBRA during the pandemic would do nothing to cover those who already
lacked insurance. It also won’t help the many Americans who continue to
receive employer-provided health care but are still prevented from going
to the doctor by massive deductibles and co-pays. In fact, the average
family with employer-provided insurance faces $4,700 in out-of-pocket
costs every year. The deductible alone for the average low-income worker
is $2,600 a year. Maintaining the status quo does nothing to address
these extraordinary costs, made worse during the pandemic economy.
Further, COBRA subsidies will only cement the inequities of our current health insurance system.Right
now, low-wage workers are, on average, enrolled in plans with low
premiums but higher deductibles. On the other hand, higher-wage
employees, often professionals, have platinum plans with much higher
premiums and far superior coverage. Expanding COBRA, which subsidizes
only premiums, would treat high-income workers who lose their jobs far
better than low-wage workers who do, even though the latter have
suffered the brunt of the economic damage wrought by the pandemic.
The
Health Care Emergency Guarantee Act would treat all people equally. For
the duration of this crisis, under the act, Medicare will cover all
medically necessary health care, including prescription drugs, for the
uninsured, whether those who have recently lost their jobs or those who
have been long without insurance. It is simply irresponsible and
dangerous to the public to allow millions of people in this country to
go without health coverage as a pandemic rips through our communities.
Medicare,
under our plan, would also temporarily cover the copays, deductibles
and other out-of-pocket costs for all medically necessary health care
for those who are already insured. Here is how this simple and efficient
plan would work: When people go to the hospital or doctor, they provide
their insurance information. If they have insurance, their provider
will bill Medicare for the out-of-pocket costs; if the individual is
uninsured, the provider will bill Medicare for the entire cost of care.
The patient will not be forced to pay any bills for their treatment.
This
proposal would prevent insurance companies from decreasing coverage and
ban surprise billing so patients don’t get unexpected charges later. It
would also prevent price gouging by pharmaceutical companies by making
sure the government pays the same lower price for prescription drugs as
the Veterans Health Administration.
Allowing
Medicare to cover out-of-pocket health care expenses during the
pandemic isn’t just the right thing to do, it’s actually less expensive
for taxpayers because, unlike COBRA, the government would not be
covering the cost of expensive monthly premiums to insurance
corporations.
The numbers make this clear. If 35 million Americans lose their
employer-provided coverage, as estimated by Health Management
Associates, subsidizing premiums to health insurance corporations
through COBRA would cost $157 billion over four months, or as much as
$472 billion over a year. And even then, these figures don’t include the
outrageously high deductibles that many people would still have to pay.
Meanwhile, the conservative Committee for a Responsible Federal Budget
estimates that allowing Medicare to cover out-of-pocket expenses for
everyonewould cost around $150 billion over four months, or only
$400 billion over a year. In other words, the Health Care Emergency
Guarantee Act provides comprehensive coverage to far more Americans
while saving taxpayers money.
The American people deserve a health care response to the pandemic
that’s simple, easy to understand and doesn’t require them to fill out
complicated forms or deal with an already stressed bureaucracy in order
to receive care. Under this proposal, everyone in the United States,
regardless of insurance coverage or immigration status, would be able to
walk into a doctor’s office to receive the care they need without
worrying about the cost.
At a time when many American families are waiting hours in food lines
and are often unable to afford groceries, whatever amount of money is
left in their pocket must be saved for the basic needs of their
families, not exorbitant health care bills. When so many of our people
are struggling economically and are terrified by the possibility of
becoming sick with the coronavirus, the government must take the burden
of health care costs off the backs of working people. The Health Care
Emergency Guarantee Act would do just that. https://www.politico.com/news/magazine/2020/04/28/covid-health-care-proposal-uninsured-medicare-212973
The pandemic has made the US healthcare crisis far more dire. We must fix the system
Before the pandemic, 87 million were uninsured or underinsured in the
US. We must finally guarantee healthcare to everyone as a human right
by Bernie Sanders and Pramilla Jayapal - The Guardian - May 2, 2020
When it comes to our current healthcare
system, the waste, cruelty and dysfunction was glaringly obvious even
before the horrific pandemic we are now experiencing. Today, as millions
of Americans lose their jobs and their healthcare benefits that come
with them, it is now virtually impossible for any rational person to
defend a system – unique among wealthy countries – that ties healthcare
to employment, and is designed only to make huge profits for the
insurance industry and drug companies, while ignoring the needs of
ordinary Americans.
Before the pandemic, 87 million people were uninsured or underinsured in our country, and more than 30,000 people died every year because they couldn’t get to a doctor when they needed to see one. More than half a million families declared bankruptcy each year because of medically related debt. One out of five Americans
could not afford the outrageously priced prescription drugs their
doctors prescribed to them. And our healthcare outcomes, from maternal
deaths to life expectancy to infant mortality, lagged behind most other industrialized nations.
And for all of that, the United States still spends nearly $11,000 on healthcare for every adult and child – more than twice the average of other major countries.
That was before the pandemic. The situation is far more dire now.
Over just the last five weeks, more than 26 million Americans
have lost their jobs and now face a crisis unique among advanced
countries: for most of them, their healthcare was tied to their jobs. In
America, unlike any other major country, when you lose your job, you
lose your healthcare. As a result, up to 35 million Americans
are estimated to see their health coverage disappear in the middle of
this Covid-19 nightmare. And premiums for those who retain their health
insurance in this crisis could increase by up to 40% . As horror stories
circulate of $34,000 coronavirus medical bills, the uninsured remain
terrified of going bankrupt just to get tested and treated for Covid-19.
In many cases, they just cannot afford to go to a doctor or the
hospital.
But it’s not just the high cost and growing number of uninsured that
expose the irrationality of the current system. It’s that the current
“system” makes absolutely no sense to anyone. It is an incredibly
byzantine and complicated collection of independent entities without a
common purpose – except greed. Think about it: In the midst of the worst
healthcare crisis in modern American history, with thousands of doctors
and nurses and other medical personnel becoming infected and sometimes dying, hospitals and clinics have, for financial reasons, been forced to lay off thousands of medical workers at a time when they are needed most.
Further, our public health system is incredibly weak, in part because
of consistent federal disinvestment and austerity that have decimated
too many public health agencies. In most states, we lack the capability
to significantly increase the level of coronavirus testing and contact
tracing we need to begin to safely reopen the economy.
Price-gouging and profiteering has affected everything from hand sanitizer to respirator prices which, in some cases, have more than quintupled – virtually overnight. Cities, states and hospitals continue to fight over scarce gloves, gowns, masks and ventilators. Four out of five
frontline nurses don’t have enough protective equipment. In the richest
country in the history of the world, nurses caring for coronavirus
patients have resorted to wearing trash bags as makeshift protective gear. That is an international embarrassment.
The current crisis has also exposed, to a horrific degree, how the
massive level of income and wealth inequality in America magnifies
healthcare inequities, and financially ravages our most vulnerable
people. Rural hospitals and community health clinics,
which often treat the poor, are on the verge of going bankrupt and
shutting down. Major outbreaks are attacking our Black, Hispanic, Native
American and undocumented communities, as well as the incarcerated and
the homeless.
State and local data show that more than 30% of reported deaths have been African American, even though they only make up less than 15%
of the population. The perverse irony of our broken for-profit
healthcare system is that black, brown, rural and low-income people are
most likely to be uninsured or underinsured, delaying or forgoing the
costly necessary treatments or prescription drugs that could prevent the
very conditions that make them most susceptible to the virus. It is no
coincidence that the poor, the working class, the sick and the elderly
disproportionately make up America’s 1m reported coronavirus infections
and over 57,000 deaths – the largest figures of any country on Earth.
If there is any silver lining in this unprecedented moment that we
find ourselves in, it is that we must use this time to reassess the
foundational institutions of American society and determine how we go
forward into a better future. With tens of thousands of Americans dying
and millions losing their jobs, how sad it would be if we learned
nothing from all that we have done wrong.
Do we really want to continue the current expensive and cruel system
that ties healthcare to our jobs? Or do we need a simple, comprehensive
and cost-effective system that understands that healthcare is a human
right for all of our people – employed or unemployed, young or old, rich
or poor?
Do we really want to continue being ripped off by the pharmaceutical
industry that charges us, by far, the highest prices in the world for
prescription drugs? Or do we want a system that negotiates drug prices
like every other country on Earth?
Do we really want to continue the complicated, wasteful and
bureaucratic system in which virtually every visit to a doctor or
hospital requires the filling out of endless forms in order to determine
how much of our deductible we have paid, what percentage of our
procedure is covered, and whether we got sick in the appropriate
“network”? Or do we want a simple system in which we go to any doctor we
choose and never see a bill, because the system is publicly funded?
Do we really want to continue having a woefully inadequate primary
healthcare system because medical and nursing school graduates, faced
with huge student debt, often gravitate to communities where they can
make big bucks? Or do we want to make sure we have an appropriate number
of medical personnel in the locations where they are most needed?
The good news is that a growing number of Americans – especially in
the face of this pandemic – believe that this dysfunctional and wasteful
healthcare system must be replaced. A poll conducted this month, for
example, indicated that 69% of all Americans – including 68% of independents and 88% of Democrats – support providing Medicare to every American.
The bad news is that the healthcare industry, which made more than $100bn
in profits last year and provides their CEOs with huge compensation
packages, will do everything possible to maintain the status quo. And
don’t be fooled: they will lobby just as hard against any lesser
proposal as they will against Medicare for All, buying politicians with
campaign contributions and spending endless amounts of money on lobbying
and advertising.
There is no question that this will be an enormous challenge – but we
can win this struggle if we engage people in the political process in a
way we have never done before. We are all in this together. In this
unprecedented moment in American history, let us stand united and
harness the solidarity and compassion that so many are now
demonstrating. Let us, finally, guarantee healthcare to all our people
as a human right. https://www.theguardian.com/commentisfree/2020/may/02/us-healthcare-system-coronavirus-pandemic-bernie-sanders-pramila-jayapal
A firm that employs doctors at 2 bankrupt Maine hospitals may seek bankruptcy itself
A staffing firm that employs some of the doctors in three rural Maine hospitals — including two that are now in bankruptcy and suing the federal government
for stimulus funding — is reportedly considering filing for bankruptcy
itself as a result of steep revenue shortfalls related to the
coronavirus.
Just as those hospitals have lost considerable revenue after
preparing to handle the pandemic, Envision Healthcare Corp. is
struggling to pay off $7 billion in debt after the crisis forced medical
systems all across the U.S. to delay lucrative elective services, according to Bloomberg.
As a result, Envision — which provides staffing to hospitals
across the country — has hired restructuring advisors and considered
seeking Chapter 11 bankruptcy protection to help manage its debts,
Bloomberg reported. It based the report on information from unnamed
sources who said the situation was fluid and subject to change.
Envision, one of the largest physician staffing firms in the
country, employs the ER doctors of Calais Regional Hospital, Penobscot
Valley Hospital in Lincoln and Down East Community Hospital in Machias.
It also employs the doctors, known as hospitalists, who see admitted
patients at Penobscot Valley Hospital.
An Envision spokesperson, Aliese Polk, did not directly
respond to a request for confirmation of the Bloomberg report or an
explanation of how a bankruptcy proceeding would affect its services at
the three Maine hospitals.
“As clinicians who live and work in the Washington and
Penobscot communities, we are focused on caring for our neighbors and
supporting our hospital partners,” Polk said in an emailed response.
“Envision Physician Services is treating COVID-19 patients and working
to mitigate the spread of the virus while continuing to provide care to
all patients seeking emergency care in the communities it serves.”
In general, companies usually continue operating during
Chapter 11 bankruptcy, but it gives them protections while they try to
reorganize their debts and return to profitability, according to the U.S. Securities and Exchange Commission. Some companies continue to operate after the process, while others end up being liquidated.
All three Maine hospitals that use Envision doctors run on
thin or negative operating margins. In the last year-and-a-half, Calais
Regional Hospital and Penobscot Valley Hospital have both sought Chapter
11 bankruptcy protection to help restructure their millions in debts.
The Calais and Machias hospitals began using Envision to staff their emergency rooms in recent months.
As part of their bankruptcy cases, the Calais and Lincoln hospitals have both just filed lawsuits
against the federal government because they were denied access to a
relief program meant to help small businesses keep their staff employed
during the coronavirus, but that has interim rules barring applicants
who are in bankruptcy. The hospitals have said that restriction is
unlawful and that they could have to close their doors by the end of
June if they don’t receive more stimulus funds.
A Calais Regional Hospital spokesperson referred any
questions to Envision, and Penobscot Valley Hospital CEO Crystal Landry
said that she had not heard reports that the company may file for
bankruptcy.
Julie Hixson, a spokesperson for Down East Community
Hospital, said: “We don’t have any real information on this and feel it
would be imprudent to prematurely speculate on their possible bankruptcy
protection filing. Regardless, it will play no part in our ability to
stay safely staffed or our ability to care for the people who come to
our emergency department.
“The people in this community have enough to deal with
right now,” Hixson added. “We want them to know that DECH and all our
provider practices are here to take care of them. We also want them to
know that Envision is committed to taking care of patients at DECH; they
have assured us of that.”
The COVID-19 Pandemic Exposes Deep Flaws In America’s Broken Healthcare System
By Margaret Flowers - Popular Resistance - April 28, 2020
The coronavirus crisis is demonstrating why it’s time we replaced a
system that exists purely for profits with one that puts public health
first.
When it comes to the number of Covid-19 cases and deaths, the United States isoff the chartscompared
to other countries. Although the USA comprises five percent of the
global population, 32 percent of Covid-19 cases and 25 percent of deaths
worldwide are there. By contrast, China, where the novel coronavirus
originated, has one-tenth of the number of cases and deaths, despite
having a population that is four times larger.
A disaster scenario is playing out across the United States,
particularly in New York City where scores of refrigerator trucks have
been brought in to hold the dead, hundreds of people are dying in their
homes without medical attention every day, mass graves are being used to
store bodies while mortuaries are overwhelmed, and health professionals
lack basic personal protective equipment (PPE), ventilators, and
dialysis machines.
Dr. Mike Pappas, a doctor there, hasdescribedthe
difficulties he and other health professionals are facing. The shortage
of PPE means doctors and nurses are reusing masks and gowns and are
sometimes working without them. They are wearing trash bags over their
bodies to protect themselves and their patients from becoming infected.
Inan interview,
Dr. Pappas spoke about the stress of not having enough staff, having to
clear hallways and the cafeteria to make bed space, and the reluctance
of hospital administrators to buy more ventilators.
As people in America struggle to wrap their heads around the twin
crises of the rampant pandemic and collapsing economy, it is easy to
blame the Trump administration for its failures to take rapid and
effective action to contain the spread of infection and provide
financial support. In reality, the roots of the crises precede Trump.
The US would have fared poorly during a pandemic under any president.
It’s the system, stupid
The current disaster exists in large part because the US healthcare
system is the opposite of what is needed. It is fragmented,
discriminatory and designed for corporate profits, not the wellbeing of
the public. Even before the pandemic, the United States had the highest
number of preventable deaths compared to other wealthy nations and a
declining life expectancy.
Nearly every facet of the system, which is twice as expensive as
other developed countries, is designed to extract profit whether it is
the hundreds of private health insurers that compete for the healthiest
enrollees while avoiding those with health conditions, or the
pharmaceutical corporations that charge whatever the market will bear.
Even hospitals areshutting down essential departmentssuch as obstetrics and pediatrics to make space for more lucrative areas like cardiology and orthopedics.
Two-thirds of US bankruptcies are caused by medical bills
There are now more than 30 million people without health insurance.
In the past five weeks, as more than 26 million people filed for
unemployment benefits for the first time, five million of themlost their health insurance.
The number of uninsured is expected to rise by more than 13 million by
June. On top of that, tens of millions of people with health insurance
can’t afford care because of the thousands of dollars in out-of-pocket
costs they must pay before their insurance benefits begin.
Even if a person has health insurance, theremay not be anywhere to gofor
care. Over the past 45 years, as the US population grew by over 100
million, the number of hospital beds shrunk by about 600,000. Hospitals
closed in rural areas because they could not bring in enough revenue to
keep their doors open. Another 453 rural hospitals are teetering on the
edge of closure out of the 1,844 that remain. In cities, hospitals that
served poor communities for over 100 years are being shuttered to make
way for luxury housing or retail space in gentrifying areas.
Another flaw that has been exposed by Covid-19 is the supply chain
for goods and equipment. In February and early March, when patients went
to hospitals with symptoms of the virus, there were few to no tests for
diagnosis because the US chose to create its own tests rather than
purchasing them from the World Health Organization. There have been
severe shortages of protective gear. States have been fighting with each
other to get basic kits as suppliersraise pricesby as much as 1,000 percent.
This situation has made the call for a national improved Medicare for
All healthcare system grow louder. If the US already had Medicare for
All, many of the problems being experienced would not exist. Under the
Medicare for All system, as defined by thecongressional billin
the House of Representatives, every person in the US would be covered
from birth to death without requiring payment before care is given.
This would alleviate the real fear Americans experience of financial
ruin. For example, in March a nurse sought care and testing for Covid-19
symptoms and subsequentlyreceived a bill for $35,000even though she was never admitted to the hospital. Two thirds of personal bankruptcies in America are because ofmedical bills.
Put people before profits
There’s a more fundamental case for a more socialized approach: it
works better. A look at healthcare systems around the world that have
performed well during the pandemic finds universal coverage, central
planning, and the principle of health over profit are essential
features. Even countries that aresuffering from economic sanctionsare doing a better job of containing the spread of infection than the United States.
Under a national improved Medicare for All, hospitals would not be
closing their doors or shutting down departments that don’t generate
high revenues in favor of more lucrative ones. Every hospital and health
facility would receive a budget to cover operating costs and capital
expenses. The days of investment companies buying up hospitals, running
them into bankruptcy and leaving them stranded would be over.
Another key feature would be that the federal government would
purchase pharmaceuticals and medical supplies in bulk to lower the cost
and ensure states have what they need. Bidding wars and price gouging
would cease to exist.
The US is an outlier in this pandemic in terms of the number of Covid-19 cases and deaths, andan expert predictsthe
next winter will be even worse as the flu season begins. But the US has
been an outlier for a long time for spending the most on healthcare and
still having poor health outcomes. Around the world, the countries that
have handled the pandemic well, such as China, South Korea, Cuba and
Venezuela, share common features of their healthcare systems: central
planning, universal coverage and a focus on public health.
Whether America finally adopts a similar system depends on what
people do to demand it, but there certainly has not been a more
opportune time to make that demand. https://popularresistance.org/the-covid-19-pandemic-exposes-deep-flaws-in-americas-broken-healthcare-system/
Two Medical Systems, Two Pandemic Responses
by Ian Austen - NYT - May 2, 2020
After lamenting in a recent Canada Letter about my inability to find an expert who could offer an informed comparison of how the medical systems in Canada and the United States were responding to the coronavirus pandemic, I soon heard from Prof. Peter Berman.
He is particularly well placed for such an assessment, afterspending 25 years teaching at Harvard,most recently as a professor of global health systems and economics at the T.H. Chan School of Public Health. Professor Berman is now based in Vancouver as the director of the school of population and public health at the University of British Columbia’s medical school.
I’ll begin the comparison with some numbers. Massachusetts, the previous home of Professor Berman, has a population of 6.8 million and British Columbia has slightly over five million residents. But the toll of the pandemic on the two areas has been significantly different. As of Friday afternoonin Massachusetts, there have been more than 62,000 reported casesand 3,562 deaths, or 52 fatalities for every 100,000 people.In B.C., there have been just 2,112 reported casesand 111 deaths or just two victims for every 100,000 residents.
Professor Berman cautioned that those numbers reflect a wide variety of factors outside the medical system like the demographic makeup of different cities and regions.
But he noted that near his old office at Harvard “there must be thousands of the world’s best hospital beds and there are three top international top hospitals within a couple blocks.” So with resources like that, why is there such a great disparity with British Columbia?
Part of the answer, for Professor Berman, can be found in how hospitals are funded and managed by the public health care systems of Canadian provinces.
“The kind of system we have in Canada — and I think in British Columbia we have a pretty well-run version of it — allows the public health authorities to essentially commandeer the hospital system. It’s a command and control thing, it’s not a coordination thing,” he said.
In the United States, Professor Berman said, hospitals are largely private institutions without any overall control.
The effect of having these different systems plays out in many ways.
“In British Columbia, the province just said: ‘We need to get ready for this, we need to free up 30 percent of the hospital beds,’” Professor Berman said. “And they instructed the health authorities to do it.”
But in Massachusetts, he said, not only was there no one to tell hospitals to clear out beds, the economics of the system work against such steps.
“If you have a private hospital where all the beds are paid for by patients and by insurance, when you have an empty bed, you have no revenue,” Professor Berman said. “So there’s a strong incentive for the hospital managers, especially in trying economic times, to be reluctant to cooperate. And then you end up with this kind of panicky atmosphere that has been happening in the U.S. where people are saying: ‘We don’t have enough beds, we don’t have enough this, we don’t have enough that.’”
By contrast, Canadian hospitals have fixed funding. The number of full or empty beds has no effect on their budgets.
The structure in the United States leads to other problems. Few American hospital administrators got together to do things like moving medical supplies and patients around between their institutions, Professor Berman said.
“They have a strong disincentive not to do that and in addition there is no one who can make them do that without a pretty heavy duty expression of police powers of the state, which we haven’t really seen happening,” he said.
Professor Berman also noted that while the American system has vast medical and scientific expertise, there’s little national coordination. Instead, responsibility has been fractured among a variety of long established agencies like the Centers for Disease Control, the National Institutes of Health and the coronavirus task force established by President Trump.
“So you see these different agencies being brought in to weigh in with their opinions without any sense of who’s really the spokesperson,” he said. In Canada however, “at a national level,Theresa Tamis doing that and then at the provincial level, we have people likeBonnie Henrydoing that. I think in the U.S., no one’s been allowed to do that.”
None of this means that Canada’s approach to the crisis and the structure of its medical system is perfect. Among other things, Professor Berman said that Canada’s health systems, which effectively treat doctors as private contractors, sometimes leads to disconnections between primary health care and the hospital systems. He also said that the country has been slow to push testing for the virus out into communities.
But none of that has led to the sort of response he’s seeing back in the United States.
“I’m a health economist,” Professor Berman said. “So the argument is always given in the United States that we have a lot of innovation, the system is very efficient and so on. But this is the other side of the argument.”
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