Nurse
practitioner Daniel Lucas-Neel II checks the temperature of a man who
asked to be screened at a pop-up Coronavirus testing site run by a free
clinic in Charleston, West Virginia on April 13, 2020. The free clinic
called West Virginia Health Right has seen an increase in people seeking
help because they lost their healthcare coverage when they lost their
jobs. (Photo: Michael S. Williamson/The Washington Post via Getty
Images)
Medicare
for All advocates had new reason to decry the U.S. system that ties the
healthcare for many to employment after a new study released Wednesday
showed an estimate 12 million Americans have lost their
employer-sponsored insurance coverage since the Covid-19 pandemic hit
earlier this year.
"At a minimum, policymakers concerned about
Americans’ health security should have the federal government pay for
all testing and treatment for COVID-19 related expenses in coming
months." —Economic Policy Institute
"Because most U.S. workers rely on their employer or a family
member’s employer for health insurance, the shock of the coronavirus has
cost millions of Americans their jobs and their access to healthcare in
the midst of a public health catastrophe," Josh Bivens, co-author of
the study and director of research at the Economic Policy Institute
(EPI), said in a statement announcing the findings.
"Tying health insurance to the labor market is always terribly
inefficient and problematic, but becomes particularly so during times of
great labor market churn," said Bivens.
The think tank pointed to a clear way to prevent job loss from equaling loss of health insurance.
"Delinking health insurance with jobs should be a top policy priority," EPI tweeted
in a thread about the study and the authors' takeaways. "The most
ambitious and transformational way to sever this link is to make the
federal government the payer of first resort for all health care
expenses—a 'single payer' plan like #MedicareForAll."
But despite growing popularity of such a system among the American public, neither the Republican nor Democratic party platforms embrace the idea, despite continued advocacy from more progressive members of Congress and activists.
Rep. Ilhan Omar, (D-Minn.) and Sen. Bernie Sanders (I-Vt.) introduced legislation this month to cover
out-of-pocket healthcare expenses of all Americans during the pandemic
by authorizing a wealth tax. Entitled the "Make Billionaires Pay Act,"
the measure would be funded by taxing the wealth gains accrued by
billionaires since March as millions of Americans lost their jobs. Both
Sanders and Omar have co-sponsored Medicare for All legislation in the
past, and the EPI study's authors urged lawmakers to act quickly.
"The coronavirus pandemic has exposed how incomplete and threadbare the U.S. safety net and social insurance system is," said Ben
Zipperer, an economist and study co-author. "In order to help millions
of Americans during the pandemic and beyond, policymakers must take
swift action to address the inequities and inefficiencies in our health
care system."
EPI also noted online Wednesday that a single-payer system would not be a job killer, as its opponents like to assert.
"Medicare for All is a hugely ambitious policy, and there's a lot to
debate about it. But the idea it would have a massive job-killing effect
is a fake story," Bivens said in an explainer video EPI shared on Twitter Wednesday.
"At a minimum, policymakers concerned about Americans' health
security should have the federal government pay for all testing and
treatment for Covid-19 related expenses in coming months," Bivens and
Zipperer wrote.
The pandemic shows America can't afford its dysfunctional health insurance system
Richard E. Besser - CNN News - August 21, 2022
For many of the nearly 28 million Americans without health insurance, complying with the CDC guidelines to stay home and in touch with a doctor when Covid-19 symptoms are present is an impossibility.
As acting director of the
Centers for Disease Control and Prevention (CDC) during the H1N1
pandemic in 2009, I learned that the agency's guidelines were only as
effective as the public's ability to follow them. Today, millions of
Americans lack the means to do so because of housing and economic
insecurity, a lack of sick leave or family medical leave, or no
transportation to drive to a clinic or testing site. But the inability
of many people to afford health insurance -- particularly people of color or those in low-wage jobs -- is one of our nation's clearest vulnerabilities during this pandemic.
There
will be a reckoning and a reassessment of American priorities after the
pandemic recedes. When this happens, lawmakers must have the vision and
courage to look beyond the political wreckage of past health care
battles and consider how to build a better system. There are many means
to a better end, but the path forward must include both increased
eligibility for subsidized coverage and cost containment measures. We
should look to build on the promise of the Affordable Care Act (ACA) to
extend coverage and fill the gaps that still exist. The coronavirus has
exposed this nation in many ways, and we must find the will to address
the inequitable, incoherent and inefficient health insurance system that
plagues us today.
Our employer-based system -- formed almost as an accident of history after World War II
-- has become increasingly ill-suited for our times. Costs are too
high, as is the number of uninsured, and the system is complex, unwieldy
and ailing. Despite the 2010 coverage expansion of the ACA that has
become a lifeline for millions, a population near that of Texas
is still uninsured, and this could grow by millions as a result of the
current economic dislocation. It is hard to find anyone who defends this
status quo.
The unreliable link between jobs and coverage, combined with ideologically driven state variations on whether to expand Medicaid,
results in a country where access to health care depends on where you
live and work. This sad truth is not new, but it has been put on display
during a pandemic that has served as both an illustration and an
accelerant of the unequal opportunities and systemic barriers that leave
Black, Hispanic and Native Americans exposed and disproportionately vulnerable.
At a time when health care needs are swelling alongside federal and state deficits,
a moral and fiscal case can be made for dramatic structural change. The
moral case is implicit, as any society that purports to value its
people -- all of its people -- cannot be satisfied with a status quo
that leaves tens of millions of people exposed and uncared for as Covid-19 rages on, with both physical and mental health needs
growing by the day. The fiscal case has perhaps never been more evident
than it is today, as health care costs unrelated to the pandemic are
straining workers, businesses and taxpayers amid a historic economic
downturn.
People with employer-sponsored insurance are considered the lucky ones.
However, a closer look reveals a different truth: higher premiums devour
ever-larger portions of take-home pay, and copays and prescription drug
costs chip away at the remainder. According to research from the Kaiser
Family Foundation, the average premium paid by workers for family
coverage has increased 71% over the past decade, while the average deductible has increased 162%. Not surprisingly, many Americans are deeply worried about paying for their health care in the months ahead.
For countless small businesses,
devastated by the pandemic, annual plan renewals have likely become a
grueling exercise to see whether the math will work. In some states,
employer-sponsored insurance pays health care providers rates that are as much as 300% higher than those paid by the Medicare program -- a reality that has led more small businesses
to end employer-sponsored plans altogether. Pharmaceutical companies
have been driving costs higher, health systems dictate prices, and
employers -- unlike the government -- have little power to effectively
negotiate. The federal tax incentive for businesses dulls the pain of
exorbitant costs, a fiscal illusion that helps obscure the need for
change.
Though
I now run the nation's largest philanthropy focused solely on health, I
don't have the hubris to suggest that I or our foundation can provide
the single answer to solve America's health insurance challenges. But
the evidence clearly demands a new path toward a better system that will
give every person access to affordable, high quality, comprehensive
health care. Doing so could save suffering, lives and our scarce
dollars.
The CDC, an agency I called home for 13 years, is uniquely equipped to
provide sound, science-based guidance for our nation during this public
health emergency. But if millions of people can't follow this advice or
have their basic medical needs met, we will all continue to pay the
price during this pandemic and for however long we tolerate this broken
and unjust system.
Labor‘We Are Being Left Behind': Retired Hollywood Actors Protest Changes to SAG-AFTRA Health Plan
Changes to the guild’s cash-strapped health plan could force
thousands of seniors off their coverage in the middle of a pandemic.
by Jeremy Fuster - The Wrap - August 25, 2020
David Lander had been a member of SAG-AFTRA long before
he got his big break as Squiggy on the classic 1970s sitcom “Laverne
& Shirley.” But now, he and thousands of retired members of
Hollywood’s actors guild are about to be thrown off of their health plan
due to drastic changes being made to cut costs in the wake of the
COVID-19 pandemic. And that’s especially bad for Lander considering that
he has spent the past 36 years grappling with multiple sclerosis.
“People need to know how serious this is,” he told TheWrap. The health
plan “has kept me alive, and I never thought it would disappear.”
Most asked to remain anonymous to protect sensitive health
information. But the retirees interviewed have been diagnosed with a
wide range of serious medical conditions, from cancer to debilitating
illnesses and disorders, all of which require treatments that cost
thousands of dollars even with Medicare.
“I had a solid plan with SAG-AFTRA. My doctors called it a Cadillac
plan,” one member, who has been with the guild for 27 years, told
TheWrap. “Now, I feel completely desolate without it. I have to enter
this Medicare process, and it is going to cost me thousands to get what
my husband needs.”
As a result of pandemic-fueled financial troubles, SAG-AFTRA on
August 12 announced significant raises to premiums and minimum earnings
requirements that it says are necessary to keep the entire plan afloat.
Quarterly premiums will jump to $375 — or $747 for those with two or
more dependents. Members under 65 will also now have to earn $25,950 or
work at least 100 days during a 12-month base earnings period to qualify
for coverage.
But the biggest change for seniors is that they will no longer be
able to count residuals — which many Hollywood retirees rely on as a
fixed income — towards that minimum earnings count.
“It’s infuriating. I’ve been in meetings telling us that this will
knock 10% of health plan members off of coverage,” said one member who
has been on a guild health plan since 1985. “Well, that 10% is going to
be scrambling to get health care in the middle of a pandemic, and the
great share of that burden will come on seniors. We are being left
behind.”
For these members, a variety of difficult decisions lie ahead. One
member said that her husband is now considering undergoing a surgical
procedure that he was told by his doctor could wait until after the
pandemic subsided. Now, he worries that the surgery will be too
expensive without the guild plan and wonders if he will have to risk
contracting COVID-19 in the hospital to undergo the operation before his
insurance expires.
Even for those without such pressing matters, rising health care
costs and long searches through health care marketplaces and
applications await. SAG-AFTRA and health plan trustees have told
retirees that they will be able to find replacements for their Medicare
supplements through the Via Benefits marketplace starting in October,
which they promise will provide expanded options and a health
reimbursement account for senior performers. Some trustees have spoken
out to reassure the membership, including former SAG president Barry
Gordon.
“I was skeptical at first, but was pleasantly surprised,” Gordon said
in a statement. “I was able to do an anonymous test run with Via
Benefits and quickly located a comparable plan at a similar price. In
fact, I actually found several options. I hope people give it a chance
rather than simply assuming that they won’t find a comparable plan.”
But not everyone has been encouraged by what they’ve seen so far in
their early searches for replacement coverage. Kathy Lander said that
she and David both enrolled in Medicare Part A and B when they turned
65, using the health plan to cover whatever Medicare didn’t. Without the
guild plan to support them, they will now have to turn to Medicare
supplements to cover David’s MS care. The cost of that supplement:
$12,000 per year.
“I’m 73 now, and it is much more expensive for this supplement plan
than it it would have been if David and I had signed up for it when we
first qualified for Medicare, because now we are considered by the
insurers to be at greater risk.” Lander said.
The production shutdown due to the coronavirus pandemic has only
worsened the financial predicament of both the health plan and the union
itself. (The guild has laid off 108 people, roughly 20% of its workforce, since March.)
While the pandemic was the trigger, the changes are also connected to
years-long trends both within the guild and nationwide. Inside
SAG-AFTRA, the health fund has seen its surplus turn into a growing
deficit since SAG and AFTRA merged in 2012. In both newsletters
announcing the changes and virtual town halls with members, health plan
trustees said that employer contributions to the plan have not kept up
with the rising costs in health care despite negotiations with health
care providers.
“The Trustees of the SAG-AFTRA Health Plan have taken a difficult but
necessary action to address financial deficits facing the plan. The
impact of healthcare costs that are continuing to skyrocket has been
exacerbated by a global pandemic that has brought our industry to a
standstill and dramatically diminished contributions to the Health
Plan,” read a statement from plan representatives.
“In order to continue to provide high-quality benefits to the
greatest number of participants, we must implement changes now in order
to preserve the long-term sustainability of the Health Plan.”
The guild’s new contract with the Alliance of Motion Picture and
Television Producers — which members approved last month with 74% of the
vote — includes a 1% increase in AMPTP contributions to the guild’s
health plan, with the option of shifting an additional .5% of the wage
increase in years 2 and 3 to the health plan or the SAG Pension
Plan/AFTRA Retirement Fund
But despite that increase in contributions from studios, the health
plan trustees now say that its not enough to stave off this new premium
surge. This has lent new fuel to the SAG-AFTRA Los Angeles local, which
vocally opposed the AMPTP contract and views the health plan changes as
evidence that not enough was done to get studios to raise caps further
on their health plan contributions. Many of the L.A. local leadership
are among the 15,000 guild members who have signed a Change.org petition urging
that the changes be overturned, and at a virtual town hall this past
weekend, the local suggested that it may take legal action to stop the
changes.
“Speaking personally and perhaps for every performer lucky enough to
actually have a pension — we don’t ‘retire,'” Frances Fisher, vice
president of the guild’s L.A. chapter, wrote on the petition page. “I
have to keep working to pay my bills. And now my dwindling residuals
don’t count as earnings to help keep my health care? During COVID when
only lucky stars are working? This is one of many things wrong here.”
Kathy Lander echoed those sentiments. “The plan has been faltering
for years, but I never thought that they would drop this on us now. And
it does feel really fishy to me that this happened just after we
approved a new AMPTP contract where we were given no warning by the
leaders that this was coming.”
Sources with knowledge of the health plan have told TheWrap that
waiting until after the pandemic subsides to make cuts would force
trustees to make steeper cuts, including a larger increase to the
earnings requirement, that would force an even larger percentage of
members off the plan, and that larger increases to employer
contributions would not have been enough to stave off the plan changes.
Health plan trustees project another $83 million deficit next year, and
warn that financial reserves would run out by 2024 without these
changes.
The SAG-AFTRA premium hikes are also tied into a larger debate over
the American health care system that has become a major factor in the
2020 presidential election. Andrew McGuire, head of single-payer
organizing network California OneCare, argued that the lack of cost
controls in the Affordable Care Act has allowed insurance companies to
raise premiums well above the rate of inflation. Worse, many guild
retirees will be turning to a private Medicare supplement marketplace
that is similarly flawed.
“What we’re seeing now with these escalating costs and Medicare
supplements is the result of decades of Republicans chipping away at the
protections Medicare offers and the ability of the government to
negotiate costs with insurers and pharmaceuticals,” he said.
During the Democratic presidential primary, one argument against
single payer by eventual nominee Joe Biden was that such a system would
take away the health care plans that unions have negotiated. It was an
argument that he took to labor town halls and to forums hosted by the
AFL-CIO. “I have a significant health care plan,” Biden said last September.
“But guess what? Under mine, you can keep your health insurance you
bargained for if you like it. If you don’t, you can move, and you can
come into a public plan.”
Should Biden defeat Donald Trump and Democrats take control of
Congress in November, many expect the party to make changes to the ACA
and consider implementing a public option instead of the
Medicare-for-All plan pushed by Sen. Bernie Sanders and the more
progressive wing of the party. But McGuire believes that many union
members like those in SAG-AFTRA who have lost their union-provided
health care during the pandemic may be more receptive to a single-payer
approach.
“The issue of single payer split a lot of unions during the primary,
but there had been some unions that didn’t buy into the idea that their
plans needed to be protected,” he said. “This pandemic is going to push
some of the more recalcitrant unions towards single payer, and that’s
going to make it more politically viable among the Democrats.”
The Fine Line Between Choice and Confusion in Health Care
Part of the U.S. debate over health care is really a debate over the definition of freedom.
by Austin Frakt - NYT - August 24, 2020
American opponents of proposed government-run health systems have long used the word “choice” as a weapon.
One
reason “Medicare for all” met its end this year has been the
decades-long priming of the public that a health system should preserve
choice — of plans and doctors and hospitals. To have choice is to be
free, according to many.
So how many Americans actually have choices, and what type of freedom do choices provide?
Making mistakes with Medicare
Current
Medicare enrollees have more choices than any other Americans — to
some, in fact, an overwhelmingly large number of them.
In 2019,
90 percent of Medicare enrollees had access to at least 10 Medicare
Advantage plans, which are government-subsidized, private-plan
alternatives to the traditional public program.
But
this is just the beginning. If Medicare beneficiaries who elect to
enroll in the traditional public program want drug coverage, they must
choose from large numbers of private prescription drug plans. In 2014,
beneficiaries could choose from an average of 28 drug plans. They can
also select private plans that wrap around traditional Medicare, filling
in some of its gaps, and this doesn’t even count plan options that may
be available through former employers as retiree benefits.
Choosing among all these options would be a challenge for anyone, or, as a Kaiser Family Foundation report put it, “a daunting task.”
“Medicare
beneficiaries are so confused, overwhelmed and frustrated with the
number of choices and the process of choosing among them, they end up
taking shortcuts,” said Gretchen Jacobson, now with the Commonwealth
Foundation and an author of the report. “Those shortcuts can lead them
to select plans that aren’t as beneficial to them as other options.”
In other words, freedom to choose is also freedom to make mistakes.
For instance, in the first year that drug plans were available to Medicare beneficiaries, economists have shown
that 88 percent of them chose a more costly plan than they could have.
This cost them 30 percent more, on average, and the tendency to select
needlessly costly plans persisted in subsequent years. This is the kind
of error, as other studies have found, that is easy to make when inundated by choices.
More
generally, without some assistance, many people don’t understand the
health insurance choices and features. Even common terms can be
confusing. In one study,
all the subjects said they understood what a “co-pay” was, but 28
percent could not answer a question testing their knowledge of the term;
41 percent couldn’t define what “maximum out-of-pocket” meant.
Of
course, just because people make mistakes when faced with choices
doesn’t imply that a single plan for all would be a better fit for more
people. It all depends on the details.
Medicaid also offers the vast majority of enrollees private-plan choices. States, on average,
offered seven plans for enrollees to choose from in 2017. Some types of
enrollees — particularly those with more complex health problems — are
not able to choose plans and are put into one that specializes in their
needs.
According to a systematic review by Michael Sparer, a
professor at Columbia University’s Mailman School of Public Health,
studies do not find
much cost savings to Medicaid programs stemming from all this choice.
But some studies indicate that private Medicaid plans do provide better
access to some types of care, including primary care.
A caution,
however: “Since Medicaid is a state-based program, broad averages don’t
tell you much about what is happening in specific states,” he said.
“Some states have been able to save money through the managed care
options enrollees can select, and some have not.”
It’s much less
clear how many choices people with employer-sponsored plans have,
because that data isn’t public. Generally speaking, employers serve as a
filter, selecting or working with insurers to devise a small number of
plans offered to employees.
What we do know
is that three in four employers offer just a single plan. These are
mostly small businesses, so only a minority of workers are employed by
them. Most workers (64 percent) are employed by firms that offer some
choice among plans. But most of these workers are at firms that offer
just two options. Does this imply workers at these firms have less
freedom?
About 4 percent of firms with more than 50 employees offer coverage in private exchanges,akin
to what the Affordable Care Act established for individuals. “Private
exchanges generated a lot of hype five years ago,” said Paul Fronstin,
director of health research at the Employee Benefit Research Institute.
“For some reason, they just never became popular.”
He
gets his coverage from an exchange that offers a whopping 60 plans.
“Choosing among them is no small task, particularly because information
about them is so confusing,” he said.
One employer that stands out in offering choices is the federal government. Federal employees
can typically choose from about two dozen plans (the number and details
vary by state). There are 28 plans in Washington and 21 in Rhode
Island, for example.
This year, all A.C.A. marketplace enrollees have choices among plans, on average about 19 of them. Some have over 100.
All told, a rough calculation suggests that about 80 percent of insured Americans have a choice of health plan.
What is ‘freedom’ in health care?
It’s
worth considering what accompanies health insurance choice for some
Americans. If you work at a company, you could lose access to affordable
coverage if you lose your job or if the company decides to stop
offering it.
Yet
others may have options, but they may not be affordable. None of this
is necessarily a condemnation of choice per se, just the nature of
health insurance choice in America today.
Medicare for all was supposed to address problems like these. As the Finnish author Anu Partanen wrote
of a single-payer system: “The point of having the government manage
this complicated service is not to take freedom away from the
individual. The point is the opposite: to give people more freedom.”
The Medicare for All Act
would have offered no choice, enrolling everyone in the same,
comprehensive plan with no out-of-pocket cost. Proponents of this
approach trust the government to devise a program suitable for all.
Detractors of it favor choices precisely because they have less faith
that government will do a better job than plans that are in competition.
For them, freedom to choose is freedom from tyranny. But too much
choice without enough guidance can be overwhelming.
By
taking the vaccine industry into full public ownership, we can provide
an internationalized response to this and future pandemics that properly
recognizes vaccines as a global public good.
Far too many people have suffered and died because our medicines and
medical products system was not prepared to respond to the COVID-19
pandemic with prompt and universal access to reliable tests, treatments,
and vaccines. Governments, non-profits, and industry in the U.S. and
around the world are working furiously to catch up. But their efforts
have been hampered by fundamental flaws in our profit-driven
pharmaceutical industry.
"We must transform the U.S. pharmaceutical sector so that our
nation can successfully combat this crisis, prepare for the next one,
and ensure that millions of people have access to the essential
medications they need to live healthy lives."
For Americans with diabetes, cancer, asthma, infectious diseases,
mental illnesses, and a myriad of other health issues, those flaws have
been causing suffering and even death for decades. From growing
shortages in essential medicines, to lagging innovation, dangerous mislabeling and misbranding,
and the highest prices in the world, America’s pharmaceutical sector is
clearly not meeting the needs of our society. The current crisis has
brought these problems into even sharper focus.
Now is the time to redesign our medicines system to effectively,
equitably, and rapidly address and anticipate crises like the current
pandemic. This can and must be done while also providing a safe,
consistent, and affordable supply of essential medicines to all,
including persons with health challenges beyond COVID-19.
Medicines were long considered a public good, off-limits to corporate
profiteering, price-gouging, and monopolizing. It is time for us to
reclaim them as such. We must transform the U.S. pharmaceutical sector
so that our nation can successfully combat this crisis, prepare for the
next one, and ensure that millions of people have access to the
essential medications they need to live healthy lives, and participate
in society and the economy.
To do so, we must take these four steps:
1. Codify open science practices that accelerate innovation,
reduce costs, and strengthen the evidence base on which our medicines
system rests.
“Open science”—broad, ready, equitable access to scientific
knowledge, and to the data that generates that knowledge, across a
drug’s entire lifecycle—is essential to focusing research and
development activity on the most crucial health needs, accelerating
R&D, expanding competition and preventing monopolization, and
reducing costs. We must provide access to the “means, methods, and materials” of biomedical innovation, including various preclinical, clinical, and financial data that is currently keptmostly hiddenby industry, government, and academia.
This could be done in two phases. In phase one, the National
Institutes of Health (NIH), the Food and Drug Administration (FDA), and
other public agencies—including the public sector vaccine and
pharmaceutical agencies we describe below—would begin discretionary sharingof preclinicaland clinical data
they hold. Government-held results of experiments and clinical trials,
and information on the costs of this research, can and should be shared
regardless of if the results are generated by government, industry, or
academia. Such data sharing would make it easier for researchers to
replicate research findings, reduce redundancy and other inefficiency,
and speed the development of new therapies.
Phase one could be achieved immediately, through agency discretion,
without changes to existing law. However, Congress could maximize public
benefit by making this data sharing mandatory.
Phase two would
extend open science to manufacturing. Sharing data and know-how on
manufacturing processes would accelerate development of new drugs,
especially biologics and biosimilars. This would break monopolies and
lower sky-high prices.
To achieve this, Congress should amend federal statute (such as the Food, Drug, and Cosmetic Act or the Biologics Price Competition and Innovation Act)
to require manufacturers and the FDA to share information that is
currently protected as trade secrets once the appropriate exclusivity
period has passed. Congress should also provide the FDA and Department
of Health and Human Services (HHS) discretion to share manufacturing
information—and clinical data, too—sooner, before the exclusivity period
expires, to accelerate competition in the event of anticompetitive
conduct or pressing public health needs. The Patent Act should also be reformed to raise the bar to patentability, require patent owners to disclose more useful information, and discouragedense patent “thickets”that overprotect drugs’ manufacturing processes.
2. Create public sector capacity for full-cycle pharmaceutical innovation and production of essential medicines.
The U.S. should establish a public full-cycle pharmaceutical research and development institute and one or more public sector pharmaceutical manufacturers.
These institutions would work together based on a new bottom line: the
public good. The American public already funds many breakthroughs in the
discovery and development of new drugs—far more than even the largest
drug companies. But we currently depend on those companies, and the
profit motive, to get those breakthroughs to patients.
Public sector institutions could work together to reimagine the
innovation cycle from beginning to end. They could direct discovery
efforts at the disease areas most important to public health, and lead
the world on open science, embracing and expanding on the data sharing
asked of industry. Additionally, as public sector actors, these
institutions would benefit from the “patient capital”—investment
not expected to turn a quick profit—needed to engage in the long-term,
uncertain process of discovering and developing truly revolutionary
science.
Public pharmaceuticals would lower prices, return revenues to public
balance sheets and reduce inefficiencies while building in surge
capacity for crises. They would foster a more resilient supply chain and
ensure broad, equitable access to new drugs through public-interest
management of its inventions. These institutions would be a source of
stable, public sector jobs (themselves an upstream investment in
health).
By breaking Big Pharma’s monopoly on our medicines supply, public
sector institutions would also begin to erode its capture of our
political system. The U.S. public sector has a long tradition of
path-breaking innovation, from development of the internet to HIV
prevention therapy to putting people on the moon. It is incumbent upon
us to also wield the full power of that public sector innovation-engine
to develop the medicines our society most needs, and assure equitable
access to them.
3. Use the full power of compulsory licensing to ensure access to essential medicines.
The federal government should use its existing compulsory licensing
power to either directly manufacture essential medicines or allow others
to do so. This will ensure adequate supplies and equitable, affordable
access. Under twodifferent U.S. statutes, we already possess full legal rights to bypass the barriers of privately-held medicine patents.
There isa long history
of the U.S. government issuing compulsory licenses to respond to crises
like the one we face today, ensuring affordable access to medicines and
technologies in the medical, energy, and other sectors.
In response to the COVID-19 pandemic, several nations are already
taking steps to issue compulsory licenses for medicines (and other
medical technologies). Beyond the present pandemic, we must also
recognize the everyday crises of lack of access to many essential
medicines—whether driven by shortages or prohibitive costs—and use
compulsory licensing any time access issues jeopardize public health.
Extending the U.S. government’s compulsory licensing power beyond
patents to trade secret manufacturing information and regulatory
exclusivities (as described above) will ensure that these barriers do
not jeopardize public health either. Compulsory licenses call for a
reasonable royalty to be paid to the holder of the patent instead of the
typical massive monopoly mark-up. Therefore, prescription drugs
manufactured through compulsory licensing can be much cheaper, while
innovators are nonetheless compensated for their work.
4. Take the vaccine industry into public ownership to assure its products are available to all.
Vaccines are not an effective market good; in fact, they are an
essential public good. Only a robust, public program of vaccine
development and production can meet our public health challenges. In a
profit-driven pharmaceutical industry, vaccines for infectious diseases
simply do not offer the kind of return on investment that owners believe
they deserve.
This has led most major pharmaceutical companies to pull out of vaccine development altogether, leaving us with a highly consolidated and non-competitive oligopoly
of producers–none with the capacity to alone produce a coronavirus
vaccine at scale. Yet, current U.S. policy is built on the presumption
that these same disinterested corporate actors are the only ones capable
of bringing vaccines to market, despite many historical examples to the
contrary. De-privatizing the vaccine industry would be a major step
towards establishing the full public sector capacity needed to assure
essential medicines are accessible to all.
Such de-privatizations in times of emergency are commonplace, and the U.S. has specific experience with public sector mobilization of vaccine development and production, including our highly successful vaccine program during World War II. A public laboratory in Canada recently led the development of the Ebola vaccine. And the U.S. public has already invested billions in vaccine development through federal agencies.
By taking the vaccine industry into full public ownership, we can
provide an internationalized response to this and future pandemics that
properly recognizes vaccines as a global public good. Vaccines developed
in the public sector could be licensed through a global pool—or
developed and marketed without patents altogether—so that they are
available to all, ensuring the prompt and equitable access necessary for
coherent public health interventions. A federal vaccine development
agency could break with industry’s tradition of secrecy and commit
itself to data sharing, accelerating innovation around the world.
Conclusion
The COVID-19 pandemic has revealed shocking deficiencies in our
country’s commitment to the health of all Americans. The choice to
prioritize corporate profits over the research, development, and
distribution of effective, affordable medicines has proven deadly, just
as it has for Americans who have been facing dire access challenges for
decades. We are confronting the challenge of our lifetimes without the
tests, treatments and vaccines we need. Yet, more and more public money
is being pumped into a system best placed to produce duplicative
“me-too” drugs that generate excessive profits but have little to no
impact on public health.
The pandemic has taught us a brutal lesson: it is time to reclaim our
medicines system for the public good. These four steps are the way to
begin.
Covid-19 and the Mandate to Redefine Preventive Care
by Daniel M. Horn, M.D.,and Jennifer S. Haas, M.D. - NEJM - August 12, 2020
As the U.S. health care system
defines the new normal for ambulatory care in the Covid-19 era, it needs
a new approach to providing routine preventive care for adults.
Concerns about contagion, competing demands, and shortages of personal
protective equipment may limit preventive care visits — most commonly
the “routine annual exam” and the Medicare Annual Wellness Visit. But
given that routine physical examinations have been shown to have limited
clinical value, we believe health care organizations should take this
opportunity to advance alternative systems for promoting evidence-based
prevention.1,2 Failure to do so will sustain or worsen the long-standing disparities in health that have been underscored by the pandemic.
Before
Covid-19, many primary care clinicians believed that annual exams did
not optimally make use of their skills. The visit often became an
exercise in checking off regulatory boxes, performing a head-to-toe
physical exam for which there is no evidence of benefit, and ordering
“routine” lab tests, many of which also lack supporting evidence. Yet
many clinicians value these exams as a time for establishing or
maintaining relationships with patients and reviewing the results of and
rationale for key preventive screening tests recommended (with a grade A
or B) by the U.S. Preventive Services Task Force (USPSTF) — a list that
is 25 items long and growing.
There are troubling disparities,
however, in use of these evidence-based preventive services according to
race, ethnicity, and socioeconomic status.3
Since use of annual exams is more common among White people than Black
people and increases with household income, such exams won’t help
address disparities in the delivery of preventive services.4
So we are faced with a long and growing list of evidence-based
preventive services to deliver to a broad population but a
low-efficiency, low-efficacy mechanism for doing so. And the pandemic
has revealed the clear and pressing need for a revamped approach.
We
believe the U.S. health care system should embrace this moment as an
opportunity to shift the locus of preventive care from face-to-face
annual exams to a strategy that focuses on population health: clinical
registries that readily identify all preventive services for which a
patient is due; annual prevention kits for patients that facilitate
widespread deployment of home-based testing, shared decision making, and
self-scheduling of preventive screening tests and procedures in more
convenient and approachable community settings; and robust
community-based strategies involving navigators to overcome health
disparities in underserved populations.
The first step in this
strategy is developing a robust, real-time clinical preventive care
registry that allows tracking of care needs asynchronously from visits.
At our institution, we have deployed a comprehensive registry that
tracks all USPSTF grade A and B preventive services and their completion
status for our approximately 250,000 primary care patients in eastern
Massachusetts, including people who receive care at three community
health centers in low-income neighborhoods. The registry is fully
integrated into our electronic health records (EHRs) and has robust
communication tools for patient outreach. Although many health systems
and EHR vendors have established registry functionality, there is a
pressing need for “smarter” registries that are interoperable across
diverse health care settings, regardless of EHR vendor, and that can
analyze utilization patterns, health conditions, and demographics to
help link patients to the best prevention approach for them. These
registries could also become shared, interactive tools for use by both
clinicians and patients to facilitate preventive care.
The second
step is to build the infrastructure for an annual “prevention kit”
received by every patient. The kit should consist of a
language-appropriate, culturally sensitive package that addresses all
indicated USPSTF grade A and B preventive services as indicated by the
clinical prevention registry. Point-of-care tests should be included to
allow preventive care to happen from patients’ homes; these could
include fecal immunochemical testing, glycated hemoglobin and lipid
testing, and perhaps soon, self-sampling of human papilloma virus for
cervical cancer screening. QR code links to standardized electronic
questionnaires should be included for depression screening, tobacco and
alcohol use, and personalized risk assessment for common conditions such
as breast cancer and cardiovascular disease. Shared-decision-making
materials for lung cancer screening, breast cancer screening intervals,
and highly controversial topics such as prostate cancer screening are
well studied and easily deployed.5 Self-scheduling instructions for all recommended procedures and imaging studies should be provided.
After
receiving the prevention kit, patients could be invited to schedule a
virtual encounter with their primary care provider to review
recommendations, engage in shared decision making on nuanced topics such
as when to start or stop each type of screening, discuss any findings
that may be of concern, and plan necessary interventions. Immunizations
and other high-value preventive care that cannot be delivered at home
could be addressed during in-person patient visits or at dedicated
immunization clinics, rather than during dedicated annual exams.
The
third step is to create specific programs to address the known
disparities in preventive care within a given population. There is a
rich body of literature supporting the effectiveness of community-based
patient navigators in closing gaps in cancer-screening rates affecting
underserved patients.3
These navigators facilitate patients’ preventive care by using
proactive outreach and motivational interviewing and by accompanying
patients to procedures such as colonoscopies. Navigators are also well
suited to systematically screening for and facilitating access to
community-based resources for addressing social determinants of health.
In addition, they can connect patients with community-based campaigns to
promote prevention, such as screening vans. Though navigation programs
cannot eliminate key social determinants of poor health, such as
poverty, educational barriers, food insecurity, and racism, they can
help make access to evidence-based preventive services more equitable.
The
primary hurdles for implementation of our plan are payment reform and
provider and patient acceptance. For a population-based prevention
strategy to succeed, the health system needs to offer prospective
payment for primary care with accountability for overall completion of
evidence-based preventive care throughout a population and a
demonstrable commitment to addressing disparities in preventive care.
Services provided by patient navigators are not billable on any payer’s
fee schedule and will not generate substantial fee-for-service revenue,
since navigators may interact with only a small proportion of a health
system’s patients. There is no reimbursable Current Procedural
Terminology (CPT) code for a preventive care kit or
shared-decision-making materials.
Health care centers that
disproportionately provide care for disadvantaged populations may face
additional barriers to implementing a population-based approach to
prevention, since they may have more limited infrastructure and
resources, particularly now that the dramatic drop in visit volume
during the pandemic has left many safety-net providers in financial
crisis. Payment reform should be prioritized to allow these sites to
move away from visit-based payments and facilitate innovative
community-based prevention programs. Perhaps the Centers for Medicare
and Medicaid Services could offer such centers one-time incentive
payments to facilitate investment in population health technology.
Gaining
clinician and patient acceptance of a new model is a second hurdle. But
a potential positive outcome of the current pandemic is that patients
may demand a care system that is more comprehensive and accessible,
promotes equity, and facilitates their engagement in preventive care
from the comfort of their home or community. Providers will face a
backlog of patients in need of management of acute and chronic health
conditions and will realize that care has to be provided more
efficiently and effectively. Both patients and clinicians will have
discovered virtual visits’ potential for discussion and counseling. If
we move to more sophisticated systems that can deliver convenient,
personalized home-based testing strategies to patients, engage patients
in their own care, and deploy evidence-based programs to ensure
equitable access to preventive services, we believe our population’s
health will be improved.
A large-scale shift to a population-based
prevention strategy is long overdue. The Covid-19 pandemic is delaying
life-saving preventive screening for millions of patients, and our
health system will struggle to catch up. Perhaps this crisis will be the
impetus for change.
In the midst of a capitalist crash and an out-of-control health crisis, two mega-industries that bear a heavy burden of responsibility for the health disaster are
reporting soaring profits. “The nation’s leading health insurers are
experiencing an embarrassment of profits,” reported the New York Times
Aug. 6. “Anthem, Humana and United Health Group second quarter earnings
are double what they were a year ago.”
The U.S. has the world’s highest number of COVID-19 cases, over
5 million, and the highest number of deaths. In addition, millions of
laid-off workers are losing health insurance.
The profits of medical insurance companies are supposed to be
capped and rebates provided to those paying health premiums. But it
turns out no rebates are planned.
Testing for the coronavirus has become another profitable
disaster. Shares in the two major COVID-19 testing companies — Quest
Diagnostics and Laboratory Corporation of America — are soaring.
The fact that it can take two weeks and even longer for
COVID-19 test results, and that results are not coordinated nationally,
makes tracking irrelevant. Nevertheless, it is very lucrative. Quest
will earn $1 billion this year — over 10% more than they estimated 6
months ago. As Quest Chief Financial Officer Mark Guinan explained,
detecting COVID-19 brings “good margins.” (“How U.S. made Covid-19 tests
a profitable disaster,” Reuters, July 23)
Every enterprise in a capitalist system exists to make a
profit. If it doesn’t make a profit, it has no purpose. A company that
makes profits, especially in the midst of a capitalist crash, is
considered a healthy investment — even if it is costing tens of
thousands of lives.
Medical insurance conglomerates are profitable — even if
millions are left uninsured and don’t get to see a doctor because
co-payments are too high. Some 41% of the population can’t afford to visit an emergency room.
Big Pharma, the largest drug companies, are enormously
profitable. So drugs, rather than health programs, are promoted for
every possible condition.
Mergers of hundreds of hospitals into giant conglomerates are
profitable, even if medical staff are laid off, advance orders of
essential personal protective and other equipment are short-listed, and
thousands of hospital beds are lost. Because of this, the U.S. has fewer hospital beds per person than 80% of the world’s nations and closes hospitals faster.
Profits first at labs, too
Quest and Lab Corp are profitable precisely because these giant
lab corporations are unwilling to invest in equipment and labs they
might not need six months from now.
Since insurers will pay even when tests are so late as to be
useless, this gives big labs an incentive to keep piling up the tests as
long as share prices keep rising, regardless of how long patients and
doctors are kept waiting for the results. Even though other, much faster tests are easily available in the U.S. and around the world, these two lab conglomerates have contracts locked in with the big hospital and insurance corporations for almost all lab tests.
Hospitals can most profitably use the interconnected software of the big corporate labs. In
the pressure to maximize income, both for-profit and nonprofit
institutions consistently push for greater privatization and the
elimination of competitors.
Public health has become an unprofitable shambles
Because U.S. health care operates on an uncoordinated,
for-profit basis, it is one of the most expensive and unequal systems in
the world. Of the more than $3.5 trillion that the U.S. population spends
annually on health care, a meager 2.5% goes to public health.
(“COVID-19 and Underinvestment in the Public Health Infrastructure of
the United States,” Milbank Quarterly, June 2020)
Public health is just not profitable. Despite
its importance, U.S. expenditures on public health have steadily been
cut at all levels, especially since the 2008 capitalist crash. Local
health departments have lost more than 55,000 staff members.
A hiring freeze at the Centers for Disease Control and Prevention has left hundreds of positions unfilled. Meanwhile, the top positions are full of political appointees connected to biotech, pharmaceutical and insurance companies.
Public health funding for preparedness and disease surveillance has been on a downward trend for decades. The CDC budget was cut another 17% in 2018.
Now the CDC issues only vague guidelines and recommendations, and its advice is watered-down or worthless. It took three months into the pandemic for it to even recommend that people wear masks.
Health care in the U.S. is a patchwork that is unraveling. The
lack of coordination and planning leaves millions without medical care
in the best of times. Now, during the COVID-10 epidemic, it has created
an uncontrolled medical crisis that is a global threat.
Countries around the world are closing their doors to travelers from the U.S. because conditions here are so out of control.
Wrong kind of infrastructure
The United States is a technologically and scientifically
advanced, modern, industrial society. But the overwhelming majority of
the people are without basic health protection. Why does this glaring
contradiction exist?
The U.S. does not lack infrastructure; it just has the wrong
kind of infrastructure. It lacks a coordinated, national, public health
infrastructure.
But it does have pre-existing infrastructures that make it incapable of dealing with health, social or environmental crises.
A majority of the federal budget’s discretionary spending goes
to the largest, most sophisticated and expensive military infrastructure
in world history — over 5,000 military bases, more than 800 of them
around the world, plus 13,000 military aircraft and 500 ships. There
are huge multibillion-dollar stockpiles of weapons of mass destruction,
nuclear and conventional. There are 1.3 million active duty personnel,
600,000 military contractors and a well-coordinated chain of command.
The U.S. also has the largest, most repressive and racist prison infrastructurein
the world: more than 2 million incarcerated, overwhelmingly people of
color. And it has the largest police force in the world by far: 800,000
cops. There are 17,985 U.S. police agencies.
The police infrastructure is so highly coordinated that an electronic fingerprint test takes
15 seconds to get results, through automated fingerprint identification
connected to police agencies all over the country. This database is
part of the repressive national infrastructure. It functions very well.
Compare that to the two weekson average to get the results of a COVID-19 test, where results nationally are totally uncoordinated.
Under capitalism, an economic crash occurs every 7 to 10 years.
This has been true for three centuries. It is expected, predictable,
unavoidable and devastating for millions of people. But it always leads to greater concentrations of capital and wealth.
The huge military machine and the giant repressive prison and
police apparatus serve an essential role. They exist to hold this global
capitalist empire together and to ensure the ability of a tiny handful
of capitalist owners and major shareholders to make superprofits.
The tremendous cost of an infrastructure for military and police repression, alongside the lack of any healthcare infrastructure, becomes more dangerous with every passing day.
Bernie Sanders Lost Again, but This Time He’ll Deliver a Victory Speech
Progressive
candidates are winning. The pandemic increased support for “Medicare
for all.” What does Mr. Sanders make of it? “He may feel a little bit
like Moses.”
by Sydney Ember - NYT - August 17, 2020
Bernie Sanders, stoop-shouldered in his navy-blue suit
jacket, adjusted his chair and stared into the camera as the livestream
began this month. He bobbed and jabbed both fists in the air, verklempt.
He smiled.
“And last but certainly not least, we have the heroine of the moment. … from St. Louis Missourrrrrri….”
It has been four months since Mr. Sanders ended his campaign for president. Since then, progressive candidates have notched once-improbable primary victories
against longtime Democratic incumbents. Each member of the so-called
Squad, the group of progressive women of color in the House, will almost
certainly return to Washington. The coronavirus pandemic has
revitalized support nationwide for progressive policy proposals
including “Medicare for all.”
In that time,
Mr. Sanders has quietly faded back into Senate life. Aside from
endorsing some fellow progressives down the ballot, he has largely kept
his focus on the public health crisis. One of his latest initiatives was
to introduce legislation that would provide “masks for all.”
On
Monday, Mr. Sanders will address the Democratic National Convention and
once again make his case for the progressive cause. Once again, he will
deliver a speech as a losing candidate to rally his loyal followers
behind another nominee.
But this is not 2016. While Mr. Sanders
nominally lent his support to Hillary Clinton at this point four years
ago, he never stopped arguing that he had been mistreated in the primary
— that the election was rigged and the entire political system was, too
— an air of grievance that his followers took with them to the
convention floor.
That 2016 gathering was overshadowed by hacked emails
from D.N.C. accounts showing party officials eager to help Mrs. Clinton
and undercut Mr. Sanders — a revelation that left the party’s Clinton
and Sanders wings deeply divided and confirmed the longstanding
complaints of bias from the Vermont senator.
Mr.
Sanders is still stubborn, still passionate and still convinced he would
have made the best president. But this year, he also appears to be
something else: at peace.
“I understand we do not agree with Joe Biden on all of the
issues — believe me, I know that, I ran against Joe Biden,” he told
hundreds of delegates on a call last month. “But at this moment, what we
need to do is engage in coalition politics with the goal of defeating
Trump.”
Allies say the success of other progressives, like
Representatives Alexandria Ocasio-Cortez of New York and Rashida Tlaib
of Michigan, has perhaps lifted some of the weight off his shoulders. He
appreciates that so many within the party have embraced at least the
spirit of his ideas — including universal health care, eliminating
student debt, and making public colleges and universities tuition-free —
even as he remains frustrated with the pace of change.
He sees
his address to the virtual Democratic convention as a pivotal moment to
summarize the arc of progressive gains. He plans to deliver the address
live from Burlington, Vt., though there will be a prerecorded version as
well in case there are technical difficulties. He will have an
eight-minute time slot. He is writing the speech by hand, on his
customary yellow legal pad.
“He may feel a little bit like Moses,”
said Barney Frank, the now-retired liberal congressman from
Massachusetts, comparing Mr. Sanders to the biblical figure who, it is
written, led his people to the Promised Land but could not enter it
himself. “And that’s a reaction he’s entitled to have.”
Like Mr.
Sanders, the party’s left flank has also been far more sanguine in its
approach to the general election than it was last time. Though some of
his delegates have refused to back the Democratic Party platform,
arguing that it does not go far enough particularly on health care,
progressives have largely taken their cues from him and fallen in line.
Even those most disenchanted with Mr. Biden appear largely intent on
backing him in November.
Their acceptance has perhaps never been clearer than it was last week after Mr. Biden announced that he had selected Senator Kamala Harris
as his running mate. Many progressive activists, organizers and elected
officials had hoped Mr. Biden would elevate one of their ideological
allies, but they still largely applauded his choice and reiterated that their highest priority was ousting President Trump.
By
most measures, it is this overwhelming desire to defeat Mr. Trump that
helps explain why the Democratic Party does not expect Sanders loyalists
to be as disruptive to the electoral prospects of the party’s nominee
as they were in 2016. Mr. Sanders is now keenly aware of the electoral
power his loyal backers wield, and that their support for Mr. Biden
could be a key factor in beating Mr. Trump. Never again, aides say, does
he want to inspire the kind of divisiveness that some in the party
still blame for the election of Mr. Trump. (Some detractors also see
sexism in this more conciliatory approach, suggesting that his
supporters harbored particularly visceral disdain for Mrs. Clinton
because she was a woman.)
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And
while Mr. Sanders’s backers still bemoan the quick coalescence of his
more moderate rivals behind Mr. Biden after the South Carolina primary,
it is harder to assert that the process was rigged. After all, it seemed
briefly as if Mr. Sanders would win.
After a strong showing in
Iowa and a victory in New Hampshire, Mr. Sanders, then considered a
front-runner, ran away with the Nevada caucuses. “We have just put
together a multigenerational, multiracial coalition, which is not only
going to win in Nevada, it’s going to sweep the country,” he told an
exultant crowd in San Antonio that February night. He predicted a
victory in Texas the next month.
That victory did not come, one of
a string of losses on Super Tuesday that ground his momentum to a halt.
Sidelined by the pandemic soon after, he surrendered the race to Mr.
Biden. “I cannot in good conscience continue to mount a campaign that
cannot win,” he said at the time, “and which would interfere with the
important work required of all of us in this difficult hour.”
Sanders
supporters say the swiftness with which his supporters have united
behind Mr. Biden is a testament to how Mr. Sanders has approached this
entire second presidential bid. They point in particular to his decision
to exit the race in early April, before the race could become
acrimonious, then almost immediately back Mr. Biden.
It was a
striking departure from 2016, when he remained in the race even after it
became increasingly clear he would not win. He did not endorse Mrs.
Clinton until days before the convention, a decision that she and her
aides maintain came too late and was too dutiful and halfhearted to
unify the party behind her. (Mr. Sanders and his associates, by
contrast, frequently note that he and Mr. Biden are friends.)
“I
do think he’s certainly playing the political role that you would ask
him to play,” said Faiz Shakir, who served as Mr. Sanders’s campaign
manager for his second presidential bid.
The two
sides are also in relatively frequent contact. Mr. Sanders has asked Mr.
Shakir to stay engaged with the Biden campaign, and Mr. Sanders and Mr.
Biden themselves speak periodically.
And few in the party would deny Mr. Sanders’s enduring influence.
“He stuck his neck out really, really far when other people wouldn’t,” said Ms. Bush, a progressive activist who beat a longtime House incumbent
in her Democratic primary this month in St. Louis. “Other people were
doing it a little here, a little there. And he just jumped all in — both
feet, all the way up to his head.”
Ms. Bush said she would think
of Mr. Sanders — “Uncle Bernie” — as her guide, though she also now
intends to follow her own path.
“I’m expecting to be able to turn
to Bernie to mentor me, but also be someone who is going to still want
Cori to be Cori and not try to turn me into someone that I’m not,” she
said.
Since dropping out of the race, Mr. Sanders has focused on
maintaining a visible public persona via livestream, using the
infrastructure he built up during his campaign. He has endorsed
progressives, including Ms. Bush. He has expressed interest in finding
ways to support the new group of progressives in the House.
Among some younger progressives, he is now regarded more as a wise elder than a crusading candidate for future office.
“I
think younger people who have been successful in electoral politics
this cycle see this moment as theirs and in fact are snatching the
torch,” said Mondaire Jones, a 33-year-old progressive lawyer who won a
Democratic House primary in New York.
When Mr. Sanders called to
endorse Mr. Jones before his primary in June, the two men talked about
the Democratic primary, and Mr. Jones said he had been sad when Mr.
Sanders dropped out. But so many young Sanders supporters had then
migrated to help him, Mr. Jones said, that it ended up being one of the
best things to happen to his campaign.
“It really, I think, was a transference of that energy,” he said.
Those
close to Mr. Sanders suggest there is more to come, that his speech on
Monday will not be his last time he engages with electoral politics.
This conviction has done nothing to blunt the sense of wistfulness for a
long political career that has most likely reached its peak.
“I think he feels that he has done so much,” said Representative Pramila Jayapal of Washington, a close ally of Mr. Sanders. “I hope
he feels that he has done so much to build the movement and elevate
these issues that never would be where they are without him.”
The senator from Vermont explains why the left still has a fighting chance.
by Elizabeth Bruenig - NYT - August 17, 2020
I have said goodbye to Bernie Sanders before. There was the
parting pageantry of the 2016 Democratic Convention where Mr. Sanders
conceded the nomination to Hillary Clinton, closing out a primary season
so tight it had given even the most pessimistic of leftists a thrill of
hope. As he called for unity against Donald Trump in his farewell, the
news network’s camera found a crying 22-year-old Bernie delegate in a Robin Hood hat, and the internet tore him apart. Laugh it up, I thought; there will be a next time.
When
next time came, the hope died in the spring and Joe Biden trounced him.
First they ignore you, then they laugh at you, then they fight you,
then you lose.
After Mr. Sanders suspended his 2020 campaign,
there was no next time to dream about. Mr. Sanders is nearly 80 years
old now, and after his heart attack on the campaign trail in 2019, he has no plans to run again. Whoever comes next, it’s not going to be Bernie.
Both
of us knew that as we spoke on the phone last week, me holed up in
insufferable midsummer Washington, D.C., and him enjoying the free New
England air.
“When I’m in Washington, I
don’t go outside,” Mr. Sanders told me, laughing, “and when I’m in
Vermont, I don’t go inside. So there you go.”
He sounded genuinely upbeat. I wasn’t. My first question made that clear: Is it all over?
“No!” he groaned, at typical volume, “I sound like my great-grandmother here. No. Don’t have that attitude.”
When
leftists express despair about Mr. Sanders’s loss, we are often
condescendingly assured that we won the war of ideas, a consolation
prize after losing the war for power. Mr. Sanders was supposed to have
won the war of ideas before, back in 2016, and two years later, a slew
of Sanders-backed candidates lost their midterm primaries. If gains made in the realm of ideas don’t translate into democratic power, what difference do they make?
Wall
Street rallied last week after Mr. Biden announced he would run with
Senator Kamala Harris, signaling to markets that they need not worry
about dramatic change
under a Biden-Harris administration. Seeing as Medicare for All, Mr.
Sanders’ flagship policy and the main focus of his young movement, did
not even make it into the Democratic platform this year, that reasoning is probably sound.
“Look,
how could it make it when you have a candidate who is strongly opposed
to it?” Mr. Sanders countered when I brought up the platform’s omission
of one of his key programs. Does that make him nervous? “Of course it
makes me nervous,” he said, but “I have a little bit of experience in
this. And here’s the thing: It takes a two-pronged approach.”
The first prong, Mr. Sanders explained, is to focus on
electing Mr. Biden — because the alternative is Mr. Trump, whose regime
could, in Mr. Sanders’ view, endanger the progressive cause in ways far
more damaging than one led by moderate Democrats. “This is a guy who
believes in voter suppression,” he said of Mr. Trump. “We are fighting
for American democracy — for whether we have free elections in this
country, or whether you will have an antidemocratic pathological liar
running this country. On this issue, there can be not one doubt.”
Mr.
Sanders’ movement relies on the idea that transformative change is
possible using the normal levers of American governance — which is a
point of contention among leftists. But it would be impossible to
accomplish without a functional democracy. Whatever Mr. Biden may be up
to, in Mr. Sanders’s view, he’s at least in favor of that much.
Which
isn’t to say he’s content with the moderate, business-friendly politics
Mr. Biden favors. And that’s where the second prong comes in.
“Now,
the day after Biden is elected, we have got to mobilize and organize
all over this country to make sure that Biden becomes as progressive a
president as is possible, that Democrats control the Senate and the
House, and that we can put sufficient pressure on Nancy Pelosi and Chuck
Schumer to carry out a progressive agenda.”
It’s worth mentioning
that Mr. Sanders has more faith in Mr. Biden than many of those among
the young left, myself included; many politicians will call one another
friends behind the podium only to seethe behind the scenes, but not Mr.
Sanders. When he says Mr. Biden is his friend, he means it: “Obviously,
Joe and I have very strong differences of opinion,” he said, “but I do
know, having talked to him, that he is more than aware of the acute,
unprecedented crisis facing this country,” a fairly high distinction in
the Sandersverse.
Yet Mr. Sanders’s scheme to nudge the Democrats
to the left wasn’t too different from the game plan he floated after Ms.
Clinton accepted the 2016 nomination. I pointed out that things hadn’t
exactly looked up since then. But Mr. Sanders found reason for optimism
in, of all things, the pandemic.
“When
millions and millions of Americans are losing their health care because
they have lost their jobs, when everybody now sees that it is crazy,
absolutely absurd to attach your health care benefits to jobs, there’s
no question in my mind that Medicare for All is winning more and more
support.” Mr. Sanders said.
Still, I couldn’t stop brooding over
whether increased support would even matter. Weren’t health insurers
perfectly pleased with the Democratic ticket this time around? Hadn’t
the Democratic Party itself fought Bernie tooth and nail?
“D’you
think?” Mr. Sanders joked. And then, soberly: “I’m not worried about how
people treated me. That’s not really what’s important right now,” he
said. There are more important things, to his mind, than himself; and
hasn’t he always said so? Not me, us: For as often as Mr. Sanders is
accused of egomania by his detractors, he isn’t calling upon his
supporters to avenge him by sitting out; quite the opposite. He still
believes change is possible.
One more time, I despaired. How am I
to trust that the young people — like myself — who make up the Sanders
movement will advance radical policies when they didn’t even turn out in sufficient numbers to give him the edge in the primaries? How are we supposed to defeat forces that are just so strong?
If
his patience was thinning by then, with all my fretting, it didn’t
show. Mr. Sanders listened, and then delivered a cornerman’s pep talk.
“These
are the people who run the world,” he said. “Of course you’re taking on
people who are enormously powerful. They own the system. They are the
system. They are the system — and it is not easy to make those
changes, OK? And it will not happen overnight. And that’s why I’m not
pessimistic about the future. We are making progress in our fight. All
right?”
Mr. Sanders cited recent primary victories by some of the
most progressive members of the House, including Alexandria
Ocasio-Cortez, Rashida Tlaib, and Ilhan Omar as examples of left
endurance, despite the machinations of powerful, moneyed opponents.
There were new primary victories for the left as well: In New York, Jamaal Bowman took out Eliot Engel in a hard-fought race, while Cori Bush pulled off a surprise upset against William Lacy Clay in Missouri. Mr. Sanders pointed out that, down the ballot — sometimes way down
the ballot — state and local governments are quietly welcoming new
members from the Democratic Socialists of America, a major left
organizing group that proudly backed Mr. Sanders.
There
are a few shoots coming up through the snow, and Mr. Sanders has no
intention of giving up on these tender blooms his movement has nurtured.
“Sometimes
people say, you know, you’re 78, all that stuff, and you’ve been doing
this for a long time — But should I be quitting now? When you look out
and you talk to these beautiful, beautiful young people who want to move
this country forward in such a decent, humane way, it really does
inspire me,” he said. “And to the degree that I have gotten those folks
involved in the political process, yeah, I am very proud of that. I
don’t know that I’ve ever done anything in my life more important than
that.”
When a Trump official praised single-payer health care
By Tsung-Mei Cheng - New York Daily News - Aug 14, 2020
U.S. Health and Human Services Secretary Alex Azar was in Taiwan this
week for what was the highest-level meeting between the U.S. and Taiwan
in decades. A focus of his trip was to highlight Taiwan’s success in
combating COVID-19 and “cooperate with the U.S. to prevent, detect, and respond to health threats.”
Azar’s praise for Taiwan’s success in health is significant, especially
given that he’s a member of a Republican administration.
Much of Taiwan’s success is due to its government-run, single-payer
health system, established 25 years ago on the recommendation of the
late Princeton economist Uwe Reinhardt, then a high-level adviser to
Taiwan’s government. Reinhardt believed that a single-payer system can
best achieve equity and cost savings. It’s also cheap to run, and the
public can easily understand it. He was right.
Today, Taiwan’s health system covers everyone with generous benefits
for about a third of the cost of American health care. This is a sharp
contrast to America, where “nearly 1 in 10 adults say cost would keep them from seeking help
if they thought they were infected.” Because everyone is insured and
access to care is easy and cheap, there are no barriers, financial or
otherwise, to receive care in Taiwan.
Second, Taiwan owes its impressive success in combatting COVID-19 to
having a national plan, which is science and evidence-based and
IT-driven. They implemented this plan almost immediately upon learning
of the first cases of the novel coronavirus in Wuhan in December 2019.
Having learned from the 2003 SARS crisis, Taiwan’s government
classified the new coronavirus as a statutory infectious disease before
the World Health Organization confirmed the human-to-human transmission
of the new coronavirus. This enabled the government to activate a whole
series of infectious disease prevention measures put in place since
2003.
Equally important, Taiwan’s government established a central command,
or CentCom, in early January to oversee and implement the national plan,
with Health Minister Shih-Chung Chen serving as commander-in-chief. The
performance of Taiwan’s COVID-19 CentCom is a study of the power of a
timely national response by leadership from the top in a national
crisis.
Taiwan’s approach to COVID-19 was two-pronged: prevent and contain.
Effective Jan. 1, 2020, travel restrictions, initially applied to
travels to and from Wuhan and other parts of China and later expanded to
include other high-risk nations, went into effect to prevent the new
coronavirus from entering Taiwan.
To contain the spread, the government began quarantine and contact
tracing, strictly enforced through a powerful IT system that links a
person’s recent travel history, visits to clinics and hospitals and
persons contacted. Violators are fined.
Taiwan’s public, to its credit, also played a crucial role.
Universal health coverage, timely actions by government, and public
trust and cooperation allowed Taiwan to escape large scale testing or
lockdown. People do wear masks. Life has been otherwise mostly normal.
Schools and businesses are open. Travels (domestic) are extremely
popular. Taiwan’s economy enjoys near full employment and is projected to grow by 1.77% in 2020.
Has Azar brought back these lessons from his visit to Taiwan? Or is it
simply too late as we are a full six months into the COVID-19 crisis? I
believe it’s not too late — if America acts now.
We need interventions that are specific to the American situation. To
start, we must step up testing. As coronavirus has spread into
communities nationwide, it is impossible to do quarantine and contact
tracing. We must use tests that give results in minutes rather than
days. This will quickly identify infected individuals regardless of
symptoms, even if they are asymptomatic.
A timely private sector initiative to scale up testing is the Rockefeller Foundation’s initiative involving six state governments.
The initiative aims to increase testing from the current 5 million to
30 million per week over the next six months. It will use tests that
give results in minutes. This is the largest public health testing
program in American history, and indeed a fine example of public-private
partnership.
There are things individual Americans can do starting immediately, if
they are not already doing them: wear a mask, keep social distancing,
wash hands often and avoid crowded places. Equally important, respect
and follow science and evidence.
COVID-19 can be controlled and contained, as we have seen in Taiwan and
many European and Asian nations. It is said that Americans will always
do the right thing after exhausting all alternatives. Now is time that
we, as a nation, come together and start doing the right things to help
save lives.
Cheng is a health policy research analyst at the Princeton School of Public and International Affairs.
The Maine Idea: Canada’s Medicare must become our Medicare
by Douglas Rook - Times Record - August 17, 2020
“Medicare for All” is the best slogan ever coined for creating a national health care system in America.
Great Britain got such a system in 1946, after voters shocked the
world by defeating Winston Churchill, and replacing him with a Labor
prime minister. Canada authorized its national system – called Medicare –
in 1966, two decades after provincial Premier Tommy Douglas did it in
Saskatchewan.
Alone among “English speaking peoples,” as Churchill called them –
and the entire developed world – the United States doesn’t guarantee
access to a national system with no consumer billing. The consequences,
in lives lost, disrupted and impoverished – along with billions of
dollars wasted every year – are almost incalculable.
But now, with our vaunted health care system performing dismally amid
coronavirus, and a progressive wave crest building, there may finally
be a chance to right this wrong.
What we did get, concurrently with Canada, was our version of
Medicare, along with Medicaid. People still confuse the names. As a
young reporter, I was taught: “Medicare for old people, Medicaid for
poor people,” and that’s still reasonably accurate.
The vast middle was then covered by comprehensive, employer-paid
private plans. The collapse of that system brought us our current
crisis.
Now, as an enrollee in our only true
“single payer” system – along with another huge cohort of “baby
boomers,” at a surprisingly youthful age – I’m studying the system’s
many peculiarities.
For example, the Part B premiums covering doctor visits rise
steadily, and are now $144.60 per month, up 6.7% from 2019. But
Advantage plans, accessing some unbelievably expensive medical
procedures and prescription benefits – albeit with co-pays and
deductibles – cost $29 or less.
It’s very odd. We penalize seniors for seeing the doctor, who might
diagnose a problem before it’s serious or chronic, while giving carte
blanche to specialists who find many ways to spend government dollars.
Here’s an actual office visit: Fee, $72, divided as follows: Co-pay,
Medicare recipient, $40; government payment, $10.05; write-off by
doctor, $21.95. I defy anyone to explain the economic logic. Despite
Medicare insurance, the patient pays 80%.
So before we decide that simply extending Medicare, and Medicaid, is
the answer, we must dig more deeply into the curious, almost unknown,
story of how Medicare came to be.
For those who remember, Medicare is linked to Lyndon Johnson’s “Great
Society” legislation featuring the Civil Rights and Voting Rights acts.
Yet Johnson never asked Congress for Medicare; his limited aim was
“pre-paid hospital care” to prevent bankruptcy among working class
Americans.
It resembled legislation advocated
by Earl Warren, Republican governor of California, way back in 1941, who
– before becoming perhaps the nation’s greatest Chief Justice – forged
the most progressive state government in the land. His own party blocked
the hospital initiative, but it remained a beachhead for reform.
The 1965 Medicare legislation was the work of Wilbur Mills, the
cantankerous chairman of the House Ways and Means Committee – ordinarily
death on spending bills, but intrigued by the technical challenge of
national health care.
Doctors, outraged over government “controlling” them by paying
hospital bills – these were dark days for the American Medical
Association – crafted a bill, intended to block Johnson’s. It covered
office visits – today’s Part B.
Republicans decided only poor people needed coverage – who could then
be stigmatized, much as today’s Medicaid recipients often are.
Reimbursements in this state-federal program are much lower than
Medicare, or private insurance.
Instead of legislative gridlock, Mills had the amazing notion of
putting all three concepts together, and Medicare/Medicaid proved
irresistible to a briefly reform-minded Congress. Retrenchment followed,
as Vietnam destroyed Johnson’s presidency, but the new programs proved
impossible to dislodge.
As a template for national coverage, however, Medicare and Medicaid
are flawed. Part B’s meager financing stems from the AMA’s fervent
opposition: Doctors got less; hospitals, too much. Advantage plans
represent Democrats’ later abandonment of a fully public program; a
Republican Congress, under President George W. Bush, offered a
prescription coverage deal in 2003.
Before Medicare or Medicaid can
become models for further expansion – the Affordable Care Act’s approach
– they should be overhauled to create positive incentives, not perverse
ones.
Payments must focus on keeping people healthy. Co-pays, if any, need
to be low, so everyone gets care. Drug prices have to be controlled, and
private Advantage plans phased out.
It will take lots of constructive, detailed work by Congress – the
kind of work our representatives seemingly have forgotten how to do.
We need patience, but not infinite patience. Before the next Congress
adjourns, we must have a pathway to national health comparable to the
world’s best.
If it seems too hard, just imagine what it will be like when the next pandemic looms on the horizon.
One of the strengths of the Republican Party is its message
discipline. When it finds an issue that works, it beats that issue to death, flogging
it long after it stops working. Thus after the Civil War, the party waved the “bloody shirt” by attacking
Democrats for opposing the war, which created a continuous run of Republican
presidents between 1868 and 1912, punctuated only by a single Democrat, Grover
Cleveland.
Another bloody shirt that Republicans have waved
forever and plan to wave again this election cycle is “socialism.” I put
the term in quotation marks because to hear Republicans tell it, virtually
everything government does is socialism; it is utterly foreign to the
United States, and it cannot be implemented without imposing tyranny on the
American people, along with poverty and deprivation such as we see today in
Venezuela, where socialism
allegedly destroyed the country.
On July 17, Vice President Mike Pence gave a preview of the
coming socialism-addled Republican strategy rather than the actual policies of
Joe Biden. Said
Pence (emphasis added):
Before us are two paths: one based on the dignity of every
individual, and the other on the growing control of the state. Our road
leads to greater freedom and opportunity. Their road leads to socialism
and decline.
President Trump set our nation on a path to freedom and
opportunity from the very first day of this administration. But Joe Biden would
set America on a path of socialism and decline….
The Biden-Sanders agenda would set America on the path of socialism
and decline….
My fellow Americans, that’s the choice we face. We have
two paths before us: one of freedom and opportunity, the other of socialism
and decline….
So that’s the choice we face, my fellow Americans: between
freedom and opportunity or socialism and decline.
The plan to run against some mythical threat of socialism
has been underway for some time. As early as October 2018, the White House Council of
Economic Advisers issued
a report attacking it, with a follow-up chapter in the 2019 Economic
Report of the President. More recently, well-known right-wing crackpot Dinesh
D’Souza published a screed on the subject, the gist of
which is that all liberals, progressives, and Democrats are socialists, as
were the Nazis. Senator Rand Paul, Republican of Kentucky, has also published The
Case Against Socialism, which one
reviewer said “does not make a case against socialism, but it does make a
convincing case against nepotism.” (Senator Paul is the son of former
Congressman Ron Paul of Texas, for whom I worked in the 1970s.)
The essence of the Republican attack is to lie about the
nature of socialism, grossly exaggerating its negative excesses while
completely ignoring its positive effects. When they are forced to concede that some
socialistic government programs–such as disease prevention or temporarily
higher unemployment benefits–may be valuable, they will nevertheless insist
that it must be resisted because it’s the first step on the slippery slope to
totalitarianism. As Senator Tom Cotton, a Republican who represents the
Confederate state of Arkansas, put it in a tweet: “Socialism
may begin with the best of intentions, but it always ends with the Gestapo.”
Republicans assert, endlessly, that the Austrian economist F.A.
Hayek proved that the welfare state leads inevitably to socialism and
tyranny in his 1944 book, The
Road to Serfdom. While Hayek’s theory may have been plausible in the
midst of World War II, all the evidence since then thoroughly contradicts it. There
is no evidence whatsoever that welfare states morph into total state control of
the economy and produce a concomitant loss of freedom and prosperity. There is
not a single case of this happening anywhere. Nor is there anything in Hayek’s
theory to explain why socialism collapsed in the Soviet Union or why
privatization rolled it back in places like Britain. (Ironically, Hayek’s relatively
expansive view of government’s legitimate functions make him a virtual
socialist to
some of today’s right-wingers.)
One myth that permeates the right-wing attack on socialism
is that America was founded as a sort of libertarian paradise based on the free market ideas of Adam Smith.
However, this perspective is very much at odds with the actual views of Smith
and the Founding Fathers.
For example, in 1763, Smith observed that the cheapest, most
miserly government with the lowest taxes and spending was not by any means the
best; on the contrary, Smith argued that it was usually a sign of barbarism. Expensive
states, he believed, were civilized, more advanced than those with puny
governments unable or unwilling to protect their citizens from the ravages of
hunger, disease, and poverty. (This
is still true.) Said
Smith:
We may observe that the government in a civilized country is
much more expensive than in a barbarous one; and when we say that one
government is more expensive than another, it is the same as if we
said that the one country is farther advanced in improvement than another. To
say that the government is expensive and the people not oppressed is
to say that the people are rich. There are many expenses necessary in a
civilized country for which there is no occasion in one that is barbarous.
Armies, fleets, fortified places, and public buildings, judges, and officers of
the revenue must be supported, and if they be neglected, disorder will ensue.
Like Smith, the Founding Fathers understood that government
has functions that go far beyond the night watchman state favored by those on
the right today. Thomas Paine, whose pamphlet Common Sense
underpinned the ideology of the American Revolution, was
a virtual socialist. His most radical work, Agrarian Justice, proposed
the revolutionary idea of a wealth tax to fund payments to citizens reaching
maturity, a precursor to today’s idea of a basic
income.
James Madison, principal author of the Constitution, agreed
that providing income to the indigent was a core government function. He wrote
in an 1820 letter:
To provide employment for the poor and support for the
indigent is among the primary, & at the same time not least difficult cares
of the public authority. In very populous Countries the task is particularly
arduous. In our favored Country where employment & food are much less
subject to failures or deficiencies the interposition of the public
guardianship is required in a far more limited degree. Some degree of
interposition nevertheless, is at all times and everywhere called for.
Of course, Alexander Hamilton was definitely a big
government kind of guy, advocating direct government aid to industry,
extensive public works, and a strong central government, which is the subject
of a new book, Radical
Hamilton, by The City University of New York economist Christian Parenti. Hamilton’s Report
on Manufactures (1791) is a virtual blueprint for extensive government
control of the economy for which he is routinely
denounced by today’s
conservatives.
A number of books detail the many ways that the early
republic harnessed the power of government to grow the economy. These include The Governmental
Habit Redux by the economic historian Jonathan R.T. Hughes, The
Great Challenge by the political scientist Frank Bourgin, and, just
published, The
Lost Tradition of Economic Equality by the historian Daniel R. Mandell.
Even the sainted Thomas Jefferson, the most libertarian of the Founding
Fathers, expanded government far beyond its constitutional limits when he made
the Louisiana Purchase.
Since they’re unable to run against the actual expansion of
the American welfare state, GOP propagandists retreat into fantasy. Always
missing from the Republican critique is any clear definition of socialism. This
is intentional. Republicans know that the term “socialism” is unpopular with
many Americans—although a growing
percentage embrace it. Republicans also know that numerous programs they
view as socialistic are nevertheless very
popular with voters. President Harry Truman often made this point in his
speeches. He
said in 1952:
Socialism is a scare word [Republicans] have hurled at every
advance the people have made in the last 20 years. Socialism is what they
called public power. Socialism is what they called social security. Socialism
is what they called farm price supports. Socialism is what they called bank
deposit insurance. Socialism is what they called the growth of free and
independent labor organizations. Socialism is their name for almost anything
that helps all the people.
Conversely, Republicans never call their many tax giveaways
to favored industrialists like Elon
Musk “socialism.” In her brilliant book, The
Entrepreneurial State, the economist Mariana Mazzucato demonstrated
that the entire tech sector rests on a foundation of government-funded research
and development that is almost never acknowledged.
According to the dictionary, socialism means that the government owns
all the means of production, and Republicans are right that this system doesn’t
work very well. But absolutely no
one is advocating that. Today’s advocates of “socialism” merely want a
somewhat expanded welfare state or even just a government that actually works.
Republicans are running against a strawman, though history tells us that has
never stopped them before.
