Want to Fix Public Health? Stop Thinking Like a Doctor.
Public health requires seeing the world from a collective perspective, but US agencies are still dominated by doctors trained to work on an individual level.
By Eric Reinhart - The Nation - February 22, 2023
Want to Fix Public Health? Stop Thinking Like a Doctor.
A changing of the guard in US public health is impending—and, with it, a chance to rejuvenate a flailing field. Anthony Fauci has retired in the shadow of one of the worst preventable disasters in history, and President Biden is moving to make new appointments while establishing a permanent White House Office for Pandemic Preparedness and Response Policy. In doing so, Biden and his advisers must confront the fact that the rot in public health is structural: It cannot be cured by simply rotating the figureheads who preside over it. Building effective national health infrastructure will require confronting pervasive distortions of public health and remaking the leadership appointment systems that have left US public health agencies captive to partisan interests.
Part of what has made public health vulnerable and a plaything of partisan politicking is the field’s gradual medicalization. Consider, for example, the history of the nation’s most important public health agency. Since 1953, every director of the Centers for Disease Control and Prevention (CDC) has had a doctor of medicine, or MD, degree as their primary credential, with secondary degrees serving mostly as résumé decor. Given that medical interventions constitute only 10–20 percent of modifiable factors affecting health, the backgrounds reflected in CDC leadership—and, likewise, at most state and local public health agencies—are notable for their consistent prioritization of narrow biomedical expertise at the expense of other fields that represent the remaining 80–90 percent of pertinent knowledge for making public health policy.
Physician and public health scholar Milton Roemer once observed that for the work of public health, “most of medical education is irrelevant.” But neither doctors’ irrelevant medical knowledge nor relative ignorance of essential fields—labor history, social anthropology, political economy, epidemiology, environmental sciences—is the most troubling aspect of physician control of public health. Rather, it’s the lack of epistemic humility, conferring an inability to recognize the limits and hazards of clinical reasoning, with which medical training often imbues them. Clinical reasoning is not only not the population-level logic of public health; it is frequently antithetical to it.
The Hazards of Clinicism
When we treat patients, doctors are appropriately oriented around taking care of the individual in front of us. We recognize that we typically cannot change their life circumstances—such as economic and housing conditions, employers’ demands, student and medical debt, neighborhood violence, or social isolation—and so we focus our clinical attention on helping them live as well as possible within existing constraints.
Public health, by contrast, is about treating populations. As with medicine, the goal of public health is to enable individuals to be free of health limitations that curtail their ability to live as they please. But public health pursues this by very different means. The task is not to help individuals accommodate to oppressive social or labor contexts. It is instead to use the power of government to change conditions that are constraining people’s freedom. The core tools of public health, then, are not just vaccines or lab tests but also policies pertaining to corporate regulation and consumer safety standards; labor protections; public jobs and housing programs; investments in community health workers, decriminalization, and decarceration; and civil rights lawsuits.
Public health doesn’t meet people where they are at; it enables them to move freely by altering their environment to facilitate risk-reducing behaviors, such as staying home from work when sick without fear of lost income. It’s not about individual risk tolerance, but about government making use of population-level tools—such as infrastructural investments in clean air and water—to lower the level of risk to which individuals are exposed by living in society. To do this effectively, public health prioritizes protections for those whose freedom is most obstructed by the current state of affairs: those who are immunocompromised, elderly, or incarcerated; migrant agricultural workers; people of color; and others especially exposed to harm. Public health should do this not simply out of altruism but because it recognizes that allowing harm to fall on vulnerable groups will ultimately return as multiplying harm for society. Public health thus requires seeing the world “from below,” rather than through the eyes of bankers, economists, or opinion writers at national newspapers.
Given that it differs from clinical medicine, public health requires different modes of analysis. For example, perverse incentives for overtreatment are rampant in US medicine and cause harm. But if these concerns are simply translated to public health scenarios without a proper accounting of population-level dynamics, they lead to conclusions that may sound smart to doctors’ ears but are, in reality, fundamentally misguided. For example, arguments against masking or Covid-19 vaccination recommendations for individuals at relatively low risk of a severe outcome, such as students in schools and colleges, often fail to address how young people are inevitably part of epidemiological networks involving teachers, custodial staff, parents, grandparents, and other more vulnerable groups. Likewise, the precautionary principle—which underlines that in cases of grave threats to public health, scientific uncertainty should not be used as grounds for delay in implementation of preventive measures—is readily apparent as a pillar of responsible health policy. But it can be confusing to clinicians who are trained to think on a smaller scale and to follow reactive protocols of treatment rather than prevention.
Today, the dominance of clinical reasoning that reduces health to individual patients while normalizing their social conditions—what I call “clinicism”—over public health is stronger than ever. Clinicism has become so pervasive that it now shapes not only physicians’ perspectives on public health but also much of what passes for public health education, such as the largely decorative, microwave “master of public health” degrees acquired by many physicians seeking leadership roles. This is in part because the individualistic paradigms of biomedicine pair very well with the economic philosophies of the two major US political parties.
Privatized Public Health
Since at least the 1990s, when Bill Clinton championed “welfare reform,” both Democratic and Republican Party leadership have embraced privatization, deregulation, and “free markets.” This economic agenda seeks the withdrawal of government from public provision of services in order to maximize opportunities for private profit-making. Not only does this exacerbate inequality; it also erodes the material basis for trust in both government and one another, leading to the plague of public distrust now undermining vaccination campaigns.
This anti-public-systems paradigm has only gained steam during Covid-19. For example, Biden’s Covid-19 response coordinator, Dr. Ashish Jha, has been advocating for the “commercialization” of Covid-19 tests, vaccines, and therapeutics. Because people can purchase these on their own, he has explained, the government should no longer be involved.
What Jha, Fauci, CDC Director Rochelle Walensky, and other officials have been tasked with implementing is a basic contradiction in terms: Privatized public health is not, in fact, a defensible policy. But because the president appoints the nation’s most powerful public health officials, economic priorities that serve partisan electoral interests have supplanted actual public health politics, thereby turning public health agencies into partisan pawns.
Rather than underlining the population-level health benefits of addressing such structural deficiencies as lax labor protections, epidemic-amplifying incarceration systems, unregulated pharmaceutical industry greed, exclusionary for-profit health care systems, and economic inequality, public health figureheads are instead compelled to look for ways to shore up existing unequal systems and to cast their political bosses in the most flattering light. If they refuse to do so, they can expect to be summarily dismissed and replaced by a more compliant physician from among the many eagerly waiting in the wings.
Public Health Should Be Political, but Not Partisan
Health officials are taking orders from politicians, while what we need is for federal scientific agencies like the CDC, NIH, EPA and Occupational Safety and Health Administration to be nonpartisan institutions that tell lawmakers what to do by publicly presenting recommendations for executive and legislative action. To enable this, their leadership should be chosen by as nonpartisan a process as possible. The National Academies of Sciences, Engineering, and Medicine (NASEM), established in 1863 to advise the federal government on matters of science and the arts, could be an ideal body for guiding such a process. Delegating authority to the NASEM to nominate for subsequent congressional confirmation the leadership of federal scientific agencies, for example, could enable these agencies to operate more independently of partisan interference and be more effective at serving the public.
Whatever approach is taken, it is vital that we acknowledge that public health agencies do work that is, by its very nature, political. If public health leaders shy away from politics, it renders their work worse than useless. But for the intrinsically political work of public health to be effective, we cannot allow it to continue to be conflated with partisan loyalties. To issue policy recommendations in the public interest, to challenge politicians and oligarchs irrespective of party affiliation, and to be trusted by the public while doing so, public health officials need to be insulated from partisan power.
Figures like Jha, Walensky, and Fauci currently possess unusually public profiles with potential to help accelerate needed changes. Each of them has faced harsh public criticism and been repeatedly put on the defensive by their public health colleagues. They are now well positioned to publicly reflect on the limitations they have faced. By doing so, they could call for the president and Congress to address the policy structures that have generated the partisan clutches by which public health officials have been restricted under Trump and Biden.
It’s only a matter of time before far-right, anti-science agendas return to power. The Biden administration should recognize that remaking the appointment structure for public health leaders is in line both with their long-term interests and those of the public they are meant to serve.
To achieve the structural reorganization of US public health is a tall order, and there’s no escaping the fact that it will require mass political movements and far more than a change to federal agencies. But if there has ever been a time when we needed a transformation of our public health agencies, this is it. We should use every resource to try to achieve change while the window of possibility remains wider than usual in the still-rippling wake of undeniable failure.
https://www.thenation.com/article/society/fix-public-health-argument/
‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions
By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud.
by Reed Abelson and Margaret Sanger-Katz - NYT - October 22, 2022
The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.
Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.
Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.
Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost. If trends hold, by next year, more than half of Medicare recipients will be in a private plan.
But a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.
The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.
As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.
Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.
The fifth company, CVS Health, which owns Aetna, told investors its practices were being investigated by the Department of Justice.
In statements, most of the insurers disputed the allegations in the lawsuits and said the federal audits were flawed. They said their aim in documenting more conditions was to improve care by accurately describing their patients’ health.
Many of the accusations reflect missing documentation rather than any willful attempt to inflate diagnoses, said Mark Hamelburg, an executive at AHIP, an industry trade group. “Professionals can look at the same medical record in different ways,” he said.
The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.
Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.
The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers. But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.
For people choosing between traditional Medicare and Medicare Advantage, there are trade-offs. Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.
But they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.
“Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” said Senator Charles Grassley of Iowa, who has investigated the industry. The efforts to make patients look sicker and other abuses of the program have “resulted in billions of dollars in improper payments,” he said.
Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.
“It’s an extremely high priority for us,” said Michael Granston, a deputy assistant attorney general for the civil division.
In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles, over the course of four presidential administrations.
Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.
C.M.S. officials declined interview requests. In a statement, the C.M.S. administrator, Chiquita Brooks-LaSure, said the agency recently sought feedback on how to improve the program. “We are committed to making sure that Medicare dollars are used efficiently and effectively in Medicare Advantage,” she said.
The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans. Nearly 80 percent of U.S. House members signed a letter this year saying they were “ready to protect the program from policies that would undermine” its stability.
“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,” said Representative Lloyd Doggett, a Texas Democrat who chairs the House Ways and Means Health subcommittee.
Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.
“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,” said Dr. Donald Berwick, a C.M.S. administrator under the Obama administration, who recently published a series of blog posts on the industry. “When you skate to the edge of the ice, sometimes you’re going to fall in.”
The program’s promise
Congress’s first attempt to design a privatized Medicare plan paid insurers the same amount for every patient with similar demographic characteristics.
In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.
But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.
Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete. Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.
In one early case, a Florida medical practice was accused of falsifying diagnoses to enrich its owner and Humana. When Humana told the doctor who owned the practice that his Medicare risk adjustment, or M.R.A., scores had increased significantly, he responded by email, according to the whistle-blower lawsuit: “Good, I am trying to buy that house based on M.R.A. scores.” The case was settled for more than $3 million.
The doctor denied any wrongdoing. Humana declined to comment on the lawsuit and said it takes compliance “seriously.” The company recently told investors it had been questioned by the Justice Department about its billing practices and expected additional litigation.
At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.
The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.
One company, Mobile Medical Examination Services, worked with Anthem and Molina, among others. Its doctors and nurses were pushed to document a range of diagnoses, including some — vertebral fractures, pneumonia and cancer — they lacked the equipment to detect, according to a whistle-blower lawsuit. According to the lawsuit, employees who drew patients’ blood often were not provided with a centrifuge or cooler; spoiled blood analyzed a day later produced strange results that could be used to justify valuable diagnoses, including kidney disease and leukemia. The company was acquired by Quest Diagnostics after the case was settled for an undisclosed amount in 2016; Quest said the company complies with all federal and state laws and regulations.
Anthem: The Justice Department suit quotes an executive describing her reluctance to change how it mined medical records for additional diagnoses. The case is continuing.
Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist.
According to the lawsuit, some patients were diagnosed with cancer and heart disease. Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.
The company declined to comment. “We will vigorously defend our Medicare Advantage business against these allegations,” Cigna said in an earlier statement regarding the lawsuit.
Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.
The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.
In a statement, the company, now named Elevance, said it would “vigorously defend our Medicare risk adjustment practices” and accused the government of holding it to standards “that are not grounded in formal statutory and regulatory rules.”
Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.
Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.
“The cash monster was insatiable,” said Dr. James Taylor, a former coding expert at Kaiser who is one of 10 whistle-blowers to accuse the organization of fraud.
At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.
Marc T. Brown, a Kaiser spokesman, said in a statement, “We are confident in our compliance with Medicare Advantage risk-adjustment program requirements,” and added, “Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from C.M.S.”
Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.
A civil trial accusing UnitedHealth of fraudulent overbilling is scheduled for next year. The company’s internal audits found numerous mistakes, according to the lawsuit, which was joined by the Justice Department. Some doctors diagnosed problems like drug and alcohol dependence or severe malnutrition at three times the national rate. But UnitedHealth declined to investigate those patterns, according to the suit.
UnitedHealth Group: A whistle-blower complaint quotes an executive’s email to a firm that was helping the company review patient medical records. A trial is scheduled for next year.
Matthew Wiggin, a spokesman for the company, called the inspector general’s report “misleading.” He said the company uses diagnostic coding to improve patient care, and noted that the whistle-blower in the lawsuit had not worked for the company in nearly a decade. “Our chart review process complies with regulatory standards,” he said, adding, “Our robust compliance program also proactively seeks to identify fraud, waste and abuse in the system.”
The company countered by suing Medicare, arguing that it wasn’t required to fix inaccurate records before regulations changed in 2014. It won at first, then lost on appeal. In June, the Supreme Court declined to hear the case.
Inaction at Medicare
Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.
Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments. Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.
The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.
Some of the agency’s top leaders have had close ties to industry. Marilyn Tavenner, a former C.M.S. administrator, left in 2015, then ran the main trade group for health insurers; she was replaced by Andy Slavitt, a former executive at UnitedHealth. Jonathan Blum, the agency’s current chief operating officer, worked for an insurer after leaving the agency in 2014, then became an industry consultant, before returning to Medicare last year.
Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”
There are signs the problem is continuing.
“We are hearing about it more and more,” said Jacqualine Reid, a government research analyst at the Office of Inspector General who has analyzed Medicare Advantage overbilling.
Kaiser Permanente: An executive discussed punishing doctors who failed to review patient records for more diseases, according to a Justice Department lawsuit. The case is continuing.
The Justice Department has brought or joined 12 of the 21 cases that have been made public. But whistle-blower cases remain secret until the department has evaluated them. “We’re aware of other cases that are under seal,” said Mary Inman, a partner at the firm Constantine Cannon, which represents many of the whistle-blowers.
But few analysts expect major legislative or regulatory changes to the program.
“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”
https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.htm
Insurer Humana lays out employer-sponsored coverage exit
The health insurer Humana will stop providing employer-sponsored commercial coverage as it focuses on bigger parts of its business, like Medicare Advantage
The health insurer Humana will stop providing employer-sponsored commercial coverage as it focuses on bigger parts of its business, like Medicare Advantage.
The insurer said Thursday it will leave the business over the next 18 to 24 months. It includes medical coverage provided through private companies and for federal government employees.
Human will still provide insurance through its military service business. It covers active duty service members, their families and retirees and totals nearly 6 million people. It also will still provide employer-sponsored specialty coverage like vision and dental benefits.
Employer-sponsored health insurance is one of the more common ways for Americans to get coverage. But at nearly a million people, it amounts to a small part of Humana’s enrollment of more than 13 million.
Humana's business largely centers on the military and Medicare Advantage plans. Those are privately run versions of the federal government’s Medicare program for people age 65 and older.
Humana also runs Medicaid coverage in several states.
CEO Bruce Broussard said in a prepared statement that the exit from employer-sponsored coverage lets Humana focus on its “greatest opportunities for growth.”
The company also said its employer-sponsored business “was no longer positioned to sustainably meet the needs of commercial members over the long term or support the company’s long-term strategic plans.”
Employer-sponsored enrollment growth has largely slowed for insurers, including market leaders like UnitedHealthcare. Companies have turned more to government-backed coverage like Medicare Advantage or Medicaid for growth.
They also have pushed deeper into managing prescription drug plans and providing care in order to control health care costs.
Humana does not expect the change to affect adjusted profit this year, which the company projects to be at least $28 per share.
Analysts forecast $28.06 per share, according to FactSet.
Shares of Humana Inc., based in Louisville, Kentucky, climbed more than $4 to $507.91 Thursday.
Comment by: Don McCanne & Jim Kahn
The key paragraph is: “Enrollment growth in employer-sponsored insurance has stagnated for many years for insurers, including market leaders like UnitedHealthcare. Insurers have turned more to government-backed coverage like Medicare Advantage or managing state Medicaid coverage for enrollment growth.” And they’re expanding their role and power: ”They have pushed deeper into managing prescription drug plans and buying care providers ...”
Private insurers are taking over public health insurance programs, reaping profits from each step in medical care funding and delivery. They recognize government largesse when they see it, and reel it in. They exercise massive market and lobbying power to create rules that help them gobble up our public health insurance resources, fueling record profits.
What intentions do they have for Medicare For All? Doesn’t this look like a setup for Medicare Advantage for All? A public insurance program under control of the private insurers? With their additional use of private equity to gain ownership of the delivery system?
We know this would waste massive resources while denying needed care. Private insurance-mediated Medicare and Medicaid are more expensive and deny or delay care through prior authorization, narrow networks, and patient cost-sharing obligations.
The battle lines are set! The wealth of the billionaires versus the health of the people. Further inertia on the part of us, the people, will result in their inevitable control.
We have the ultimate move that can tip the balance toward health, if we act soon. That, of course, is to implement an improved, publicly-administered Medicare that covers everyone. What do we want to use the people's money for? More wealth for the wealthy, or more health for the people?
Bill seeking universal health care in Oregon gets first look
The legislation would create a state board charged with coming up with a plan for single-payer health care in Oregon.
Oregon lawmakers are considering a bill that could put the state on the path toward a single-payer health care system as it implements a landmark constitutional amendment guaranteeing access to medical care.
In a packed hearing room, the Senate Health Care Committee on Monday heard initial testimony on Senate Bill 704, which would establish the framework for how the state will ensure universal access to health care. The legislation is in direct response to the passage of Measure 111, a 2022 ballot initiative that made Oregon the first state to adopt a constitutional right to affordable health care.
The bill would create the Universal Health Plan Governance Board, a 9-member panel representing various health care interests and the public appointed by the governor. The board would be responsible for coming up with a plan for a single-payer health care plan by 2025. It’ll also oversee the implementation of the plan once it’s implemented in 2027.
The committee has received written testimony from nearly 200 people or organizations in favor of the legislation. Supporters told the committee it’ll put Oregon on the path to containing rising health care costs that’ve hindered access and burned patients with financially ruinous bills.
“It is well past time that we got corporate profit and private insurance out of Oregonians’ healthcare,” state Rep. Travis Nelson, a Portland Democrat and chief sponsor of the bill, told the committee. “What providers and treatments are available to us shouldn’t be determined by commercial bottom lines.”
Several supporters said the legislation would advance the work of the Joint Task Force on Universal Health Care, which was created by the Legislature in 2019 and produced a report in 2022 laying out how a single-payer system could be implemented in Oregon.
Sharon Meieran, a Multnomah County commissioner and emergency room doctor, told the committee that high costs from the “fundamentally flawed health care system” are leading reasons why people file for bankruptcy or become homeless.
The bill also had detractors.
Tom Holt, a lobbyist for the Oregon Association of Health Underwriters, told the committee that there is room for improvement in the health care system. But he said the task force report used “heroic assumptions” that didn’t explain how savings from a single-payer plan would be realized.
“From the (association’s) standpoint, this just seems like a project destined to ultimately crash and burn,” he said.
Elise Brown, lobbyist for America's Health Insurance Plans, told the committee her group also opposed the bill. She pointed to numbers showing that Oregon has an uninsured rate of 6% and that the state has adopted other measures intended to further expand coverage and control costs.
“We’re eager to work with the state to help the remaining uninsured Oregonians enroll in the appropriate coverage,” she said, pointing to Vermont’s difficulties in adopting universal health access. “But a complete overhaul of the health care system now is the wrong approach.”
You can reach Jake at Jake@thelundreport.org or via Twitter @jakethomas2009.
Bryant DC. Single-payer Health Care: Financial Implications for a Physician.
Abstract
Dr. Loh: Healthcare may be headed for a cliff
Dr. Irving Kent Loh - VCStar.com-January 28, 2023
Doom and gloom are never attractive topics to read about, particularly when dealing with healthcare. But have you wondered why it takes months to get a doctor’s appointment, or why you can’t get a hospital bed and need to sit in in an emergency department for hours or even days, even if there are open beds available.
This is a thumbnail overview of what’s happening to our healthcare system. The imagery for me is being a passenger in a car out of control sliding in slow motion towards a cliff, in broad daylight with a bunch of people fighting for the steering wheel, none of whom really know how to drive. And with that, here we go.
Healthcare starts with a basic equation: there are patients with problems, and there are clinicians with the skills to help deal with those problems. Pre-pandemic, this equation was already an issue. The pandemic made this a crisis because of the huge imbalance suddenly foisted on a marginally compensated system. There was a sudden surge of very ill patients and a drop-off in available healthcare personnel. It was always a logistical trick to make sure there were enough doctors, nurses, and support staff to keep up with the clinical load.
Suddenly, there were care providers who were getting sick, getting so overworked dealing with an invisible and potentially lethal enemy that didn’t care if you were a healthcare worker, and dealing with emotional roller coasters of saving some, but losing many, lives in an isolated and barren workplace in which they were physically and emotionally exhausted.
If you’ve been paying attention, there are stories every week of healthcare systems losing hundreds of millions if not billions of dollars despite the huge bills patients get. Although there is considerable opportunity to minimize waste and redundancy (another topic), we still are dealing with an almost $4 trillion annual healthcare, actually sickcare, cost in this country.
For those of you who run businesses, you realize that most overhead is people — salaries, benefits, retirement costs. That’s why when trouble hits the bottom line, leadership looks to cut workers. Even giants like Google, Amazon, Microsoft, Meta, and innumerable non-tech companies are shedding employees. The companies try to further control expenses by holding down wages.
The nurses, who do the grunt work are overworked, understaffed, and during the pandemic suffered from the the lack of PPE, got sick, and were not rewarded; doing good does not pay for food, rent, childcare, and good quality of life enough to justify the sacrifices. They were called heroes, but most felt of them felt they were just doing the job they were trained for in a crisis in which they could help. Post-pandemic, they are now line items on P&L statements for healthcare systems. Thousands of nurses across the country have staged or threatened to stage strikes in order to get better nurse-patient ratios so they can provide better care for their patients, control their work hours, and get better compensation. Hospitals and healthcare facilities are hemorrhaging nurses because of difficult working environments.
The hospitals need staff, so they turn to locums, or travelers, who are nurses who will go where there is need and hospitals that are willing to pay for them. The hospitals end up paying much higher wages plus benefits (but not retirement) to get these nurses, thus paradoxically costing the hospitals even more money. And these locums nurses have to learn the hiring hospital’s routines and staff, and thus may reduce efficiency. Moreover, they have no loyalty to that hospital so they can just leave when they feel the need or when another facility offers them more money. In fact, any nurse can leave their long-term employer to become a locum and work down the street for more money and better hours. Monetary musical chairs with a stethoscope.
There are a huge number of doctors in the boomer generation who were and are getting ready to retire. And, of course, there are a huge number of boomer generation patients who are getting the illnesses and frailties of, ahem, maturing. This clearly exacerbates the equation imbalance in a not good way. During the pandemic, many of these doctors and nurses stayed on under difficult circumstances. Now that the perception of the pandemic has waned, they’re physically tired, mentally exhausted, and suffering end-stage burnout. When they retire, they will leave even fewer providers. Those clinicians remaining who are personable and great get lots of patients, but may opt to close their practices to new patients to provide better care for those they already have. Supply and demand is the rule, so it make take months to get appointment with a doctor or nurse practitioner.
Support staff that make it work — pharmacies, outpatient care facilities, therapists, laboratories, people who clean the ER, surgery suites, hospitals, are also in the same boat. Hospital beds may be empty, but no support staff are available; management opts to close services and whole hospitals. Patients who don’t have insurance or a primary care clinician use ERs as PCP, taking up time and resources, possibly uncompensated. If it were not for Obamacare, even more hospitals would have closed their emergency rooms.
So when hospitals run in the red, they cut costs by cutting staff, which affects available services, and then hospitals themselves are abandoned, leaving patients with further distances to travel for needed routine and emergency care. Complications and mortality rates rise.
And there’s another problem. Fewer of our smartest youth want to go into healthcare: they spend at least 10 years training to be the best they can be, then work for a corporation whose operations are run by bean counters who tell them what they can do for an allowed cost. That sounds like pre-baked frustration. It’s a tough, though intellectually and emotionally rewarding, journey. But I think it always requires that spark of altruism to be the final driver.
The cost of a bachelor’s degree leaves an average debt of $60,000; tack on an additional average $250,000 for medical school. Seventy-three percent of graduating docs have debt. No wonder they don’t do public health but instead do plastic surgery where they mostly don’t have to deal with insurance companies and it’s a cash business. There are easier ways to support one’s family and have a good quality of life if one is smart and driven. One solution has been to get more doctors from other countries, but that only exacerbates the problem elsewhere. In fact, this is a problem not just in the U.S., but worldwide.
Over two decades ago, I realized that technology could be part of solution. I still feel that way, but technology is not a complete fix. Legislative and bureaucratic reforms are needed. All are topics for future articles.
This column hopefully gives you a glimmer of why it will get harder to get care down the road. And speaking about the road, we should hope someone gets control of this car … soon.
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