The Moral Crisis of America’s Doctors
by Eyal Press - NYT - June 15, 2023
Some years ago, a psychiatrist named Wendy Dean read an article about a physician who died by suicide. Such deaths were distressingly common, she discovered. The suicide rate among doctors appeared to be even higher than the rate among active military members, a notion that startled Dean, who was then working as an administrator at a U.S. Army medical research center in Maryland. Dean started asking the physicians she knew how they felt about their jobs, and many of them confided that they were struggling. Some complained that they didn’t have enough time to talk to their patients because they were too busy filling out electronic medical records. Others bemoaned having to fight with insurers about whether a person with a serious illness would be preapproved for medication. The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.
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In July 2018, Dean published an essay with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Military psychiatrists use the term to describe an emotional wound sustained when, in the course of fulfilling their duties, soldiers witnessed or committed acts — raiding a home, killing a noncombatant — that transgressed their core values. Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”
The article was published on Stat, a medical-news website with a modest readership. To Dean’s surprise, it quickly went viral. Doctors and nurses started reaching out to Dean to tell her how much the article spoke to them. “It went everywhere,” Dean told me when I visited her last March in Carlisle, Pa., where she now lives. By the time we met, the distress among medical professionals had reached alarming levels: One survey found that nearly one in five health care workers had quit their job since the start of the pandemic and that an additional 31 percent had considered leaving. Professional organizations like National Nurses United, the largest group of registered nurses in the country, had begun referring to “moral injury” and “moral distress” in pamphlets and news releases. Mona Masood, a psychiatrist who established a support line for doctors shortly after the pandemic began, recalls being struck by how clinicians reacted when she mentioned the term. “I remember all these physicians were like, Wow, that is what I was looking for,” she says. “This is it.”
Dean’s essay caught my eye, too, because I spent much of the previous few years reporting on moral injury, interviewing workers in menial occupations whose jobs were ethically compromising. I spoke to prison guards who patrolled the wards of violent penitentiaries, undocumented immigrants who toiled on the “kill floors” of industrial slaughterhouses and roustabouts who worked on offshore rigs in the fossil-fuel industry. Many of these workers were hesitant to talk or be identified, knowing how easily they could be replaced by someone else. Compared with them, physicians were privileged, earning six-figure salaries and doing prestigious jobs that spared them from the drudgery endured by so many other members of the labor force, including nurses and custodial workers in the health care industry. But in recent years, despite the esteem associated with their profession, many physicians have found themselves subjected to practices more commonly associated with manual laborers in auto plants and Amazon warehouses, like having their productivity tracked on an hourly basis and being pressured by management to work faster.
Because doctors are highly skilled professionals who are not so easy to replace, I assumed that they would not be as reluctant to discuss the distressing conditions at their jobs as the low-wage workers I’d interviewed. But the physicians I contacted were afraid to talk openly. “I have since reconsidered this and do not feel this is something I can do right now,” one doctor wrote to me. Another texted, “Will need to be anon.” Some sources I tried to reach had signed nondisclosure agreements that prohibited them from speaking to the media without permission. Others worried they could be disciplined or fired if they angered their employers, a concern that seems particularly well founded in the growing swath of the health care system that has been taken over by private-equity firms. In March 2020, an emergency-room doctor named Ming Lin was removed from the rotation at his hospital after airing concerns about its Covid-19 safety protocols. Lin worked at St. Joseph Medical Center, in Bellingham, Wash. — but his actual employer was TeamHealth, a company owned by the Blackstone Group.
E.R. doctors have found themselves at the forefront of these trends as more and more hospitals have outsourced the staffing in emergency departments in order to cut costs. A 2013 study by Robert McNamara, the chairman of the emergency-medicine department at Temple University in Philadelphia, found that 62 percent of emergency physicians in the United States could be fired without due process. Nearly 20 percent of the 389 E.R. doctors surveyed said they had been threatened for raising quality-of-care concerns, and pressured to make decisions based on financial considerations that could be detrimental to the people in their care, like being pushed to discharge Medicare and Medicaid patients or being encouraged to order more testing than necessary. In another study, more than 70 percent of emergency physicians agreed that the corporatization of their field has had a negative or strongly negative impact on the quality of care and on their own job satisfaction.
There are, of course, plenty of doctors who like what they do and feel no need to speak out. Clinicians in high-paying specialties like orthopedics and plastic surgery “are doing just fine, thank you,” one physician I know joked. But more and more doctors are coming to believe that the pandemic merely worsened the strain on a health care system that was already failing because it prioritizes profits over patient care. They are noticing how the emphasis on the bottom line routinely puts them in moral binds, and young doctors in particular are contemplating how to resist. Some are mulling whether the sacrifices — and compromises — are even worth it. “I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. She notes that the term moral injury was originally coined by the psychiatrist Jonathan Shay to describe the wound that forms when a person’s sense of what is right is betrayed by leaders in high-stakes situations. “Not only are clinicians feeling betrayed by their leadership,” she says, “but when they allow these barriers to get in the way, they are part of the betrayal. They’re the instruments of betrayal.”
Not long ago, I spoke to an emergency physician, whom I’ll call A., about her experience. (She did not want her name used, explaining that she knew several doctors who had been fired for voicing concerns about unsatisfactory working conditions or patient-safety issues.) A soft-spoken woman with a gentle manner, A. referred to the emergency room as a “sacred space,” a place she loved working because of the profound impact she could have on patients’ lives, even those who weren’t going to pull through. During her training, a patient with a terminal condition somberly informed her that his daughter couldn’t make it to the hospital to be with him in his final hours. A. promised the patient that he wouldn’t die alone and then held his hand until he passed away. Interactions like that one would not be possible today, she told me, because of the new emphasis on speed, efficiency and relative value units (R.V.U.), a metric used to measure physician reimbursement that some feel rewards doctors for doing tests and procedures and discourages them from spending too much time on less remunerative functions, like listening and talking to patients. “It’s all about R.V.U.s and going faster,” she said of the ethos that permeated the practice where she’d been working. “Your door-to-doctor time, your room-to-doctor time, your time from initial evaluation to discharge.”
Appeasing her peers and superiors without breaching her values became increasingly difficult for A. On one occasion, a frail, elderly woman came into the E.R. because she was unable to walk on her own. A nurse case manager determined that the woman should be discharged because she didn’t have a specific diagnosis to explain her condition and Medicare wouldn’t cover her stay, even though she lived alone and couldn’t get out of a chair to eat or go to the bathroom. A. cried with the woman and tried to comfort her. Then she pleaded with the hospitalist on duty to admit her. A.’s appeal was successful, but afterward, she wondered, What are we being asked to do? When we spoke, A. had taken a leave from work and was unsure if she would ever go back, because of how depleted she felt. “It’s all about the almighty dollar and all about productivity,” she said, “which is obviously not why most of us sign up to do the job.”
That’s not always clear to patients, many of whom naturally assume that their doctors are the ones who decide how much time to spend with them and what to charge them for care. “Doctors are increasingly the scapegoats of systemic problems within the health care system,” Masood says, “because the patient is not seeing the insurance company that denied them the procedure, they’re not seeing the electronic medical records that are taking up all of our time. They’re just seeing the doctor who can only spend 10 minutes with them in the room, or the doctor who says, ‘I can’t get you this medication, because it costs $500 a month.’ And what ends up happening is we internalize that feeling.”
I spoke to a rheumatologist named Diana Girnita, who found this cycle deeply distressing. Originally from Romania, Girnita came to the United States to do a postdoc at Harvard and was dazzled by the quality of the training she received. Then she began practicing and hearing patients complain about the exorbitant bills they were sent for routine labs and medications. One patient came to her in tears after being billed $7,000 for an IV infusion, for which the patient held her responsible. “They have to blame someone, and we are the interface of the system,” she said. “They think we are the greedy ones.” Fed up, Girnita eventually left the practice.
Some doctors acknowledged that the pressures of the system had occasionally led them to betray the oaths they took to their patients. Among the physicians I spoke to about this, a 45-year-old critical-care specialist named Keith Corl stood out. Raised in a working-class town in upstate New York, Corl was an idealist who quit a lucrative job in finance in his early 20s because he wanted to do something that would benefit people. During medical school, he felt inspired watching doctors in the E.R. and I.C.U. stretch themselves to the breaking point to treat whoever happened to pass through the doors on a given night. “I want to do that,” he decided instantly. And he did, spending nearly two decades working long shifts as an emergency physician in an array of hospitals, in cities from Providence to Las Vegas to Sacramento, where he now lives. Like many E.R. physicians, Corl viewed his job as a calling. But over time, his idealism gave way to disillusionment, as he struggled to provide patients with the type of care he’d been trained to deliver. “Every day, you deal with somebody who couldn’t get some test or some treatment they needed because they didn’t have insurance,” he said. “Every day, you’re reminded how savage the system is.”
Corl was particularly haunted by something that happened in his late 30s, when he was working in the emergency room of a hospital in Pawtucket, R.I. It was a frigid winter night, so cold you could see your breath. The hospital was busy. When Corl arrived for his shift, all of the facility’s E.R. beds were filled. Corl was especially concerned about an elderly woman with pneumonia who he feared might be slipping into sepsis, an extreme, potentially fatal immune response to infection. As Corl was monitoring her, a call came in from an ambulance, informing the E.R. staff that another patient would soon be arriving, a woman with severe mental health problems. The patient was familiar to Corl — she was a frequent presence in the emergency room. He knew that she had bipolar disorder. He also knew that she could be a handful. On a previous visit to the hospital, she detached the bed rails on her stretcher and fell to the floor, injuring a nurse.
In a hospital that was adequately staffed, managing such a situation while keeping tabs on all the other patients might not have been a problem. But Corl was the sole doctor in the emergency room that night; he understood this to be in part a result of cost-cutting measures (the hospital has since closed). After the ambulance arrived, he and a nurse began talking with the incoming patient to gauge whether she was suicidal. They determined she was not. But she was combative, arguing with the nurse in an increasingly aggressive tone. As the argument grew more heated, Corl began to fear that if he and the nurse focused too much of their attention on her, other patients would suffer needlessly and that the woman at risk of septic shock might die.
Corl decided he could not let that happen. Exchanging glances, he and the nurse unplugged the patient from the monitor, wheeled her stretcher down the hall, and pushed it out of the hospital. The blast of cold air when the door swung open caused Corl to shudder. A nurse called the police to come pick the patient up. (It turned out that she had an outstanding warrant and was arrested.) Later, after he returned to the E.R., Corl could not stop thinking about what he’d done, imagining how the medical-school version of himself would have judged his conduct. “He would have been horrified.”
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Concerns about the corporate takeover of America’s medical system are hardly new. More than half a century ago, the writers Barbara and John Ehrenreich assailed the power of pharmaceutical companies and other large corporations in what they termed the “medical-industrial complex,” which, as the phrase suggests, was anything but a charitable enterprise. In the decades that followed, the official bodies of the medical profession seemed untroubled by this. To the contrary, the American Medical Association consistently opposed efforts to broaden access to health care after World War II, undertaking aggressive lobbying campaigns against proposals for a single-payer public system, which it saw as a threat to physicians’ autonomy.
But as the sociologist Paul Starr noted in “The Social Transformation of American Medicine,” physicians earned the public’s trust and derived much of their authority because they were perceived to be “above the market and pure commercialism.” And in fields like emergency medicine, an ethos of service and self-sacrifice prevailed. At academic training programs, Robert McNamara told me, students were taught that the needs of patients should always come first, and that doctors should never allow financial interests to interfere with how they did their jobs. Many of these programs were based in inner-city hospitals whose emergency rooms were often filled with indigent patients. Caring for people regardless of their financial means was both a legal obligation — codified in the Emergency Medical Treatment and Labor Act, a federal law passed in 1986 — and, in programs like the one McNamara ran at Temple, a point of pride. But he acknowledged that over time, these values increasingly clashed with the reality that residents encountered once they entered the work force. “We’re training people to put the patient first,” he says, “and they’re running into a buzz saw.”
Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults, who order more elective surgeries and are less likely to be on Medicaid. It can be seen in emergency rooms that were understaffed because of budgetary constraints long before the pandemic began. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the health care industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. McNamara estimates that the staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms. Once in charge, these companies “start squeezing the doctors to see more patients per hour, cutting staff,” he says.
As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.
Philip Sossenheimer, a 30-year-old medical resident at Stanford, told me that these changes had begun to precipitate a shift in self-perception among doctors. In the past, physicians “didn’t really see themselves as laborers,” he notes. “They viewed themselves as business owners or scientists, as a class above working people.” Sossenheimer feels that it is different for his generation, because younger doctors realize that they will have far less control over their working conditions than their elders did — that the prestige of their profession won’t spare them from the degradation experienced by workers in other sectors of the economy. “For our generation, millennials and below, our feeling is that there is a big power imbalance between employers and workers,” he says.
Last May, the medical residents at Stanford voted to form a union by a tally of 835 to 214, a campaign Sossenheimer enthusiastically supported. “We’ve seen a boom in unionization in many other industries,” he told me, “and we realize it can level the power dynamics, not just for other workers but within medicine.” One thing that drove this home to him was seeing the nurses at Stanford, who belong to a union, go on strike to advocate for safer staffing and better working conditions. Their outspokenness stood in striking contrast to the silence of residents, who risked being singled out and disciplined if they dared to say anything that might attract the notice of the administration or their superiors. “That’s a big reason that unionization is so important,” he says.
The Stanford example has inspired medical residents elsewhere. Not long ago, I spoke with a group of residents in New York City who were thinking about unionizing, on the condition that I not disclose their identities or institutional affiliations. Although the medical profession has been slow to diversify, the residents came from strikingly varied backgrounds. Few grew up in wealthy families, judging by the number of hands that went up when I asked if they’d taken on debt to finish medical school. “Anyone here not take on debt?” said a woman sitting on the carpet in the living room where we gathered, prompting several people to laugh.
Having a union, one resident explained, would enable the group to demand better working conditions without having to worry about getting in trouble with their superiors or losing fellowship opportunities. They would be able to advocate for patients rather than apologizing to them for practices they considered shameful, another added. When I asked what they meant by shameful, I learned that a number of the residents had trained at a hospital that served an extremely poor community with a limited number of I.C.U. beds — beds that during the pandemic were sometimes given to wealthy “V.I.P.” patients from other states while sicker patients from the surrounding neighborhood languished on the general floor.
Forming unions is just one way that patient advocates are finding to push back against such inequities. Critics of private equity’s growing role in the health care system are also closely watching a California lawsuit that could have a major impact. In December 2021, the American Academy of Emergency Medicine Physician Group (A.A.E.M.P.G.), part of an association of doctors, residents and medical students, filed a lawsuit accusing Envision Healthcare, a private-equity-backed provider, of violating a California statute that prohibits nonmedical corporations from controlling the delivery of health services. Private-equity firms often circumvent these restrictions by transferring ownership, on paper, to doctors, even as the companies retain control over everything, including the terms of the physicians’ employment and the rates that patients are charged for care, according to the lawsuit. A.A.E.M.P.G.’s aim in bringing the suit is not to punish one company but rather to prohibit such arrangements altogether. “We’re not asking them to pay money, and we will not accept being paid to drop the case,” David Millstein, a lawyer for the A.A.E.M.P.G. has said of the suit. “We are simply asking the court to ban this practice model.” In May 2022, a judge rejected Envision’s motion to dismiss the case, raising hopes that such a ban may take effect.
Until the system changes, some doctors are finding ways to opt out. I spoke to several physicians who have started direct-care practices, in which patients pay a modest monthly fee to see doctors who can offer them more personalized out-of-network care, without having to answer to administrators or insurers. Diana Girnita, the rheumatologist who became disillusioned by the astronomical bills her patients kept receiving, started a direct-care practice in her specialty in 2020. One afternoon not long ago, I sat in on a virtual appointment she had with a patient who wished to remain anonymous, a 32-year-old veteran with an athletic build who began to experience severe joint pain several months earlier. He asked his primary-care physician for a referral to see a rheumatologist after a blood test showed a high level of antinuclear antibodies (ANAs), which can be a sign of an autoimmune disorder. He called every doctor’s office he could find within a 100-mile radius of his house, but none could schedule him for months. His wife then stumbled upon Girnita’s name online and called her office, and he got a virtual appointment the next day.
The meeting I sat in on was a follow-up appointment. When it began, Girnita relayed some good news, telling him that his ANA level had fallen and that his lab results indicated he did not have an autoimmune disease. The patient was visibly relieved, though he was still experiencing persistent pain in his wrist. Girnita advised him to get an MRI, which she said she could order for $800 — a fraction of the amount that hospitals typically charged. One advantage of the direct-care model was that physicians negotiated with labs and imaging centers for tests and services, Girnita told me, bypassing the corporate middlemen (insurers, pharmacy-benefit managers) that drove up health care costs.
When he went to medical appointments in the past, Girnita’s patient told me later, the doctors he saw were often brusque. “They come in, tell you the medicine you’re going to take and that’s it,” he said. His first appointment with Girnita lasted an hour, the minimum amount of time she allotted to all patients in their initial consultations. During the follow-up appointment I observed, Girnita spent half an hour answering his questions; she never cut him off and did not seem rushed or harried. At the end of the appointment, he thanked her profusely, in a way that made it clear he was not accustomed to such treatment. It was a novel experience not only for the patient but also for Girnita, who told me that, in the past, she often had to squeeze appointments into seven-minute time slots. Before starting her direct specialty-care practice, she added, she spent so many hours doing bureaucratic work that she barely had time to see her family, much less her patients. “The direct-care model is designed to rebuild trust,” she said, “and to re-establish a normal relationship between physicians and patients.”
Of course, the model is far from a panacea: Many doctors struggle to attract enough patients to make a living, which is a problem for specialists like Girnita, who rely on referrals from primary-care doctors. Girnita told me she understood why some doctors were choosing to leave the profession altogether. Two physicians she knew had switched careers recently, an impulse she fears will overcome more and more of her peers in the years to come, especially those who chose to become doctors for altruistic reasons. “They didn’t quit because they don’t like medicine,” she said. “They were both wonderful physicians.”
And even running direct-care practices, doctors cannot fully escape the frustrations and injustices of the health care system. A few months earlier, Girnita told me, a patient came to her after having a severe allergic reaction to an ulcer medication that his insurer had switched him onto because it no longer covered the drug he’d been taking. Girnita told me she had called her patient’s insurer every week as his condition deteriorated. When she finally got through, she was told they needed 30 days to process the appeal. Girnita was livid. “They are literally putting this patient in danger — it is sick,” she said. “This is sick medical care.”
https://www.nytimes.com/2023/06/15/magazine/doctors-moral-crises.html
I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours.
by Aaron Carroll - NYT - June 13, 2023
Despite just experiencing a pandemic in which over one million Americans died, health care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best.
When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a “private” system, or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings.
Moreover, no one has a system quite as complicated as ours.
A more productive debate might benefit from looking around the world at other options. Many people resist such arguments, however. They think that our system is somehow part of America’s DNA, something that grew from the Constitution or the founding fathers. Others believe that the health care systems in different countries couldn’t work here because of our system’s size.
I think those are bad excuses. Our employer-based insurance system is the way it is because of World War II wage freezes and I.R.S. tax policy, not the will of the founders. And much of health care is regulated at the state level, so our size isn’t really an outlier. We could change things if we wanted to.
In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with I.U.’s Kelley School of Business, and more recently, with the Commonwealth Fund and AcademyHealth, to New Zealand, Australia and Singapore.
Australia and New Zealand are two other countries with single-payer systems out there, although their systems differ greatly from that of Canada and from each other’s. Unlike our neighbor to the north, they allow private insurance for most care, which can be applied to pay for faster access with more bells and whistles. In addition, Australia’s system has fairly high out-of-pocket payments, in the form of deductibles and co-pays.
France’s system is close to a single-payer one because almost everyone gets insurance from one of a few collective funds, mostly determined by employment or life situations. They also have out-of-pocket payments and expect most people to pay upfront for outpatient care, to be reimbursed later by insurance. That’s something even the United States system doesn’t do.
Britain, on the other hand, has no out-of-pocket payments for almost all care. Private insurance is optional, as it is in other countries, to pay for care that may come faster and with more amenities. Relatively few people purchase it, though.
As I’ve written about before, Singapore has a completely different model. It relies on individuals’ personal spending more than almost any other developed country in the world, with insurance only really available for catastrophic coverage, or for access to a private system that, again, relatively few use.
America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do.
Universal coverage matters, not how we get there.
The pandemic should have been an eye-opener in terms of how much work we need to do to repair the cracks in our health care foundation. Unfortunately, we seem to have moved on without enough focus on where we fall short and what we might do about it. It’s outrageous that the health care system hasn’t been a significant issue in the 2024 presidential race so far.
Even if we did have that national conversation, I fear we’d be arguing about the wrong things. We have spent the last several decades fighting about health insurance coverage. It’s what animated the discussions of reform in the 1990s. It’s what led to the Affordable Care Act more than a decade ago. It’s what we are still arguing about. The only thing we seem able to focus on concerns insurance — who provides it, and who gets it.
No other country I’ve visited has these debates the way we do. Insurance is really just about moving money around. It’s the least important part of the health care system.
Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.
Only the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured, it also distracts us from doing anything else. We have all types of coverage schemes, from veteran’s affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together they don’t work well. They’re all too complicated, too inefficient and fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.
When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.
If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services.
Public delivery systems are essential, but so are private options.
What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system.
The care delivered in these public systems is often just as good, in terms of outcomes, as what is delivered in the private system. The same doctors often work in both settings. What is different is the speediness of care and the amenities that come with it. If you choose to get care in a public system, you often have to wait in line. Most often, the wait doesn’t lead to worse outcomes, and people accept it because it’s much cheaper than paying for private hospital care. Those who don’t want to wait, or feel they can’t, can pay more to jump the queue.
In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But “more” isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)
In the United States, on the other hand, most care is provided by private hospitals, either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost. Our focus on what pays — acute care — also leads us to ignore primary care and prevention to a larger extent.
I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.
I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.
Strong social policies matter.
I have been to Singapore twice now to learn about the country’s health care system, and twice I’ve watched my hosts spend significant time showcasing their public housing apparatus. More than 80 percent of Singaporeans live in public housing, which involves more than one million flats that were built and subsidized by the government. Almost all Singaporeans own their own homes, too, even publicly subsidized ones; only about 10 percent of them rent.
Because of government subsidies, most people spend less than 25 percent of their income on housing and can choose between buying new flats at highly subsidized prices or flats available for resale on an open market.
This isn’t cheap. It’s possible, though, because the government is only spending about 5 percent of G.D.P. on health care. This leaves a fair amount available for other social policies, such as housing.
Other social determinants that matter include food security, access to education and even race. As part of New Zealand’s reforms, its Public Health Agency, which was established less than a year ago, specifically puts a “greater emphasis on equity and the wider determinants of health such as income, education and housing.” It also specifically seeks to address racism in health care, especially that which affects the Maori population.
In Australia I met with Adam Elshaug, a professor in health policy at the Melbourne School of Population and Global Health. When I asked about Australia’s rather impressive health outcomes, he said that while “Australia’s mortality that is amenable to, or influenced by, the health care system specifically is good, it’s not fundamentally better than that seen in peer O.E.C.D. countries, the U.S. excepted. Rather, Australia’s public health, social policy and living standards are more responsible for outcomes.”
Addressing these issues in the United States would require significant investment, to the tune of hundreds of billions or even trillions of dollars a year. That seems impossible until you remember that we spent more than $4.4 trillion on health care in 2022. We just don’t think of social policies like housing, food and education as health care.
Other countries, on the other hand, recognize that these issues are just as important, if not more so, than hospitals, drugs and doctors. Our narrow view too often defines health care as what you get when you’re sick, not what you might need to remain well.
When other countries choose to spend less on their health care systems (and it is a choice), they take the money they save and invest it in programs that benefit their citizens by improving social determinants of health. In the United States, conversely, we argue that the much less resourced programs we already have need to be cut further. The recent debt limit compromise reduces discretionary spending and makes it harder for people to access government programs like food stamps. As Mr. Elshaug noted, doing the opposite would lead to better outcomes.
We are already doing what other countries can’t.
These other countries’ systems are not perfect. They face aging populations, expensive new technologies and often significant wait times — just like ours does. Those problems can make some people quite unhappy, even if they’re not more unhealthy.
When I asked experts in each of these countries what might improve the areas where they are deficient (for instance, the N.H.S. has been struggling quite a bit as of late), they all replied the same way: more money. Some of them lack the political will to allocate those funds. Others can’t make major investments without drawing from other priorities.
Singapore might, though. With its rapidly aging population, it likely needs to spend more than the around 5 percent of G.D.P. Jeremy Lim, director of the country’s Leadership Institute for Global Health Transformation and an expert on its health care system, said that while Singapore will need to spend more, it’s very unlikely to go above the 8 percent to 10 percent of G.D.P. that pretty much all developed countries have historically spent.
That is, all of them except the United States. We currently spend about 18 percent of G.D.P. on health care. That’s almost $12,000 per American. It’s about twice what other countries currently spend.
With that much money, any of these countries could likely solve the issues it faces. But spending substantially more on health care is something they feel they cannot do. We obviously don’t have that issue, but it’s intolerable that we get so little for what we spend.
We cannot seem to do what other countries think is easy, while we’ve happily decided to do what other countries think is impossible.
But this is also what gives me hope. We’ve already decided to spend the money; we just need to spend it better.
https://www.nytimes.com/2023/06/13/opinion/health-care-reform.html
Editor's Note -
The following clipping makes the case that our hybrid commercial/public system of health insurance is just too complicated -period. It doesn't have to be that way. All we need is the political will to change it - no small order.
-SPC
It’s Not Just You: Many People Confront Health Insurance Obstacles on Care and Bills
by Reed Abelson - NYT - 06-15-2023
A majority of Americans with health insurance said they had encountered obstacles to coverage, including denied medical care, higher bills and a dearth of doctors in their plans, according to a new survey from KFF, a nonprofit health research group. As a result, some people delayed or skipped treatment.
Those who were most likely to need medical care — people who described themselves as in fair or poor health — reported more trouble; three-fourths of those receiving mental health treatment experienced problems.
“The consequences of care delayed and missed altogether because of the sheer complexity of the system are significant, especially for people who are sick,” said Drew Altman, the chief executive of KFF, formerly known as the Kaiser Family Foundation.
The survey also underscored the persistent problem of affordability as people struggled to pay their share of health care costs. About 40 percent of those surveyed said they had delayed or gone without care in the last year because of the expense. People in fair or poor health were more than twice as likely to report problems with paying medical bills than those in better health, and Black adults were more likely than white adults to indicate they had trouble.
Why It Matters: Delayed care can endanger health.
Nearly half of those who encountered a problem with their insurance said they could not satisfactorily resolve it. Some could not obtain the care they had sought, while others said they paid more than expected. Among the nearly 60 percent who reported difficulty with their insurance coverage, 15 percent said their health had declined.
“This survey shows it’s not enough to just get a card in your pocket — the insurance has to work or it’s not exactly coverage,” said Karen Pollitz, the co-director for KFF’s patient and consumer protections program.
People have a hard time understanding their coverage and benefits, with 30 percent or more reporting difficulty figuring out what they will be required to pay for care or what exactly their insurance will cover.
“Insurances are way more complicated than they should be,” said Amanda Parente, a 19-year-old college student in Nashville who is covered under her mother’s employer plan. She was surprised to find that her out-of-pocket costs spiked recently when she sought treatment for strep throat. While she realized her co-payments would be higher, “I guess we didn’t know how drastic it was going to be,” she said.
Background: Insurance coverage is confusing to everyone.
Navigating the intricacies of coverage and benefits were similar regardless of what kind of insurance people had. At least half of those surveyed with private coverage, through an employer, those with an Obamacare plan, or a government program like Medicare or Medicaid, said they experienced difficulties.
People might be unhappy with their coverage because they were already concerned about higher inflation and potential layoffs, said Christopher Lis, the managing director of global health care intelligence at J.D. Power, which found that consumer satisfaction with insurers had declined in a recent study. “We’ve got economic conditions that set the stage for concern around coverage and benefits,” he said.
Insurers say people generally report being happy with their plan, and 81 percent of those surveyed by KFF gave their insurance high ratings. “Health insurance providers are committed to improving access, affordability and convenience for all Americans and will continue to find innovative solutions to work toward this common goal,” said David Allen, a spokesman for AHIP, a trade group that represents insurers.
What’s Next: How to haggle with insurers or appeal?
Also striking among the survey’s findings was how unaware people were about pursuing appeals of denied coverage and how to go about doing so.
“Most people don’t know who to call,” Ms. Pollitz said. Sixty percent of insured adults surveyed did not know they had a legal right to appeal, and about three-fourths said they did not know which government agency to contact for help, particularly respondents with private insurance.
State insurance regulators oversee fully insured policies sold to individuals and small businesses, and the federal Department of Labor has jurisdiction over employer-sponsored insurance.
Many of the problems people have with their insurance could be solved by enforcing existing rules, like federal regulations requiring private insurers to issue understandable explanations of benefits and to maintain accurate, current lists of doctors and hospitals within their networks.
https://www.blogger.com/blog/post/edit/3936036848977011940/8988024324990998313
Hospice Is a Profitable Business, but Nonprofits Mostly Do a Better Job
Nearly three-quarters of hospice organizations are now for-profit. Complaints of fraud and profiteering are growing.
by Paula Span - NYT - July 11, 2023
In the nearly 20 years that Megan Stainer worked in nursing homes in and around Detroit, she could almost always tell which patients near death were receiving care from nonprofit hospice organizations and which from for-profit hospices.
“There were really stark differences,” said Ms. Stainer, 45, a licensed practical nurse. Looking at their medical charts, “the nonprofit patients always had the most visits: nurses, chaplains, social workers.”
The nonprofit hospices responded quickly when the nursing home staff requested supplies and equipment. By contrast, she said, “if you called and said, ‘I need a specialized bed,’ with for-profits it could take days — days when the patient is in a bed that’s uncomfortable.”
Ms. Stainer, now a private duty nurse and certified death doula in Hamburg, Mich., also found nonprofits more willing to keep patients enrolled and for-profits more prone to “live discharge” — removing patients from hospice ostensibly because they no longer met the criteria for declining health, then re-enrolling them later.
“It seemed like people were being discharged when they still needed their services,” Ms. Stainer said. “There never seemed to be a logical reason.” But long enrollments and live discharges can help hospices boost profits and avoid financial penalties, analysts have pointed out.
Researchers have for years reported that there are, indeed, substantial differences overall between for-profit and nonprofit hospices; a new study based on family caregivers’ experiences provides additional evidence.
Medicare began covering hospice care four decades ago, when most hospices were nonprofit community organizations relying heavily on volunteers. It has since become a growth industry dominated by for-profit businesses.
In 2001, 1,185 nonprofit hospices and just 800 for-profits provided care for Americans with terminal illnesses who were expected to die within six months. Twenty years later, almost three-quarters of the nation’s 5,000-plus hospices were for-profits, many affiliated with regional or national chains.
The shift was probably inevitable, said Ben Marcantonio, interim chief executive of the National Hospice and Palliative Care Organization, which represents both types along with some government hospices. Roughly half of Americans who die each year now turn to hospice. The number of Medicare beneficiaries enrolling in hospice rose to 1.7 million in 2020 from 580,000 in 2001.
“The growth of for-profit providers is largely responding to growing need,” Mr. Marcantonio said. “It’s evolved within a health care system that not only accepts but encourages for-profit providers. To think hospice would be exempt from that forever probably wasn’t realistic.”
Yet the proliferation of for-profit hospices has stoked fears that dying patients and their families are being shortchanged to improve companies’ bottom lines.
The most recent report from MedPAC, the independent agency advising Congress on Medicare spending, found that in 2020, for-profits received 20.5 percent more from Medicare than they spent providing services. The margin for nonprofits, whose daily per-patient expenditures are higher, averaged 5.8 percent.
“We’re not going to get profiteering out of the business until we make changes,” said Larry Atkins, chief policy officer of the National Partnership for Healthcare and Hospice Innovation, which represents about 100 nonprofit hospices.
He acknowledged, only a bit grudgingly, that “there are a lot of sophisticated players on the for-profit side that do a decent job.”
Barbara Reiss discovered that in 2017, when her 85-year-old mother was dying of cancer at her home in River Ridge, La. A for-profit hospice proved “very responsive to us,” she said, even when the family called for advice at 2 a.m. The hospice provided all the necessary supplies and drugs and sent nurses regularly.
“When we were really having trouble, they came,” Ms. Reiss said. Her mother died peacefully, and the family turned to the same for-profit hospice three years later, when her father died in assisted living at 95.
But numerous studies have documented that as a group, nonprofits provide better care. All hospices within a geographic area receive the same daily payment per Medicare beneficiary, but patients enrolled in nonprofits receive more visits from nurses, social workers and therapists, according to a 2019 study by the consulting firm Milliman.
For-profits are more likely to discharge patients before they die, a particularly distressing experience for families. “It violates the implicit contract hospice makes, to care for patients through the end of life,” Dr. Atkins said.
Dr. Joan Teno, a Brown University health policy researcher, and her team reported in 2015 on these “burdensome transitions,” in which patients were discharged, hospitalized and then readmitted to hospice.
That happened to 12 percent of patients in for-profits affiliated with national chains, and to 18 percent of patients enrolled in for-profits that weren’t chain-affiliated — but to only 1.4 percent of patients in nonprofit hospices.
Dr. Teno’s latest study, undertaken with RAND Corporation, analyzes the family caregiver surveys that Medicare introduced in 2016. Using data from 653,208 respondents from 2017 to 2019, the researchers ranked about 31 percent of for-profit hospices as “low performers,” scoring well below the national average, compared with 12.5 percent of nonprofits.
More than a third of nonprofits, but only 22 percent of for-profits, were “high performers.” In 2019, the Department of Health and Human Services’ inspector general’s office also reported that most hospices it identified as low-performing were for-profits.
Apart from such differences, the hospice industry has been plagued by fraud in several states. Investigations by The Los Angeles Times in 2020 and by the state auditor found that scores of new for-profit hospices were getting certified and billing Medicare in California.
The number far outstripped need, and dozens of hospices shared common addresses, the auditor noted, concluding that “numerous indicators suggest large-scale hospice fraud and abuse” in Los Angeles County. Last year, the state imposed a moratorium on hospice licenses.
In November, national hospice associations urged Medicare to take action in Nevada, Arizona and Texas, where similar patterns of growth and abuse have emerged.
Researchers and critics have also raised alarms about private equity firms acquiring hospice organizations and, intending to resell them within a few years, reducing costs through measures like cutting staff. Most of those acquisitions were previously nonprofits.
Advocates, researchers and industry leaders have long lists of reforms they think will fight fraud and improve services, from strengthening the way Medicare conducts quality surveys to shifting from a per-diem payment model to more individualized reimbursement.
“It’s clear we need to strengthen oversight, but we must also modernize payment programs to meet the needs of patients and make it harder for people to game the system,” Representative Earl Blumenauer, an Oregon Democrat who has long been involved in end-of-life legislation, said in an email.
Meanwhile, families seeking reliable, compassionate hospice care for loved ones need to undertake research, at a time when they shouldn’t have to, to select a provider. “It’s not as simple as avoiding all for-profits,” Dr. Teno said. “Because of the variations, you have to really look at the data.”
The Medicare.gov website notes not only which hospices are nonprofit but also other quality measures. (The National Hospice Locator also provides such information, and the CaringInfo site from the National Hospice and Palliative Care Organization offers general guidance.)
Dr. Teno advised caution if more than 40 percent of a hospice’s patients have dementia or are in assisted living facilities or nursing homes, both associated with higher profit margins.
Quality hospices provide not only “routine home care,” the most common type of hospice service, but also higher levels of care when needed, including inpatient services. Look for a hospice with a four- or five-star rating, she added, although some geographic regions lack one.
Most family caregivers still give hospice care high approval ratings, despite its changes and problems, but the need for improvement is clear.
“It’s a small segment of the health care system, but it’s such an important one,” Dr. Teno said. “If you screw it up, people don’t forget.”
Obamacare Mandate for Preventive Care Is Restored, for Now
Health plans must pay for all types of preventive care, including a pill to prevent H.I.V., while an appeals court deliberates whether to strike down part of the Affordable Care Act.
by Sarah Kliff - June 12, 2023
Lawyers reached a deal on Monday to keep the Affordable Care Act’s mandate requiring health plans to cover preventive care at no cost to patients.
A district court in Texas ruled in March that part of the requirement was unconstitutional. The decision took effect immediately, meaning insurers no longer had to cover certain types of preventive care, including a pill to prevent the spread of H.I.V.
The Fifth Circuit Court of Appeals temporarily stayed the ruling last month, bringing the health law’s provision back into effect. The appeals court also asked the two parties — a group of Texas residents and businesses challenging the law, and the Biden administration, which is defending it — to come to a compromise on how much of the mandate should be put on hold while it weighed its decision.
The deal they reached leaves the provision almost fully in tact, requiring a vast majority of health plans to continue providing preventive care at no charge. The agreement includes an exemption for the small businesses and individuals challenging the provision; these entities will be allowed to use a plan that does not cover all preventive services if they can find a health insurer who offers it.
The appellate court, which is expected to rule on the preventive care mandate’s constitutionality later this year, still has to approve the lawyers’ agreement.
Health policy experts describe the mandate as one of the most transformative policies of the health law, known as Obamacare, because it could prevent worsening disease and higher costs later on. It is also popular, with 62 percent of the public recently saying it was “very important” that it stay in place.
Before the Affordable Care Act’s passage, in March 2010, patients sometimes faced big bills for preventive care such as birth control or colonoscopies. Since the mandate took effect, studies have shown, more Americans have received blood pressure screenings, cholesterol screenings and flu vaccines.
In March, Judge Reed O’Connor of the Federal District Court for the Northern District of Texas ruled that part of the mandate was unconstitutional because an independent panel advising the government on what benefits to cover did not have the proper authority to do so.
Judge O’Connor’s ruling did not undo the entire preventive services mandate, but said it should not cover services that the panel, the United States Preventive Service Task Force, had recommended since 2010.
The newer services included three types of screenings: one for anxiety in children, another for unhealthy drug use and a third for weight gain in pregnant women. The mandate also included a recommendation that people at high risk for H.I.V. take PrEP, a daily pill that is highly effective at preventing the transmission of the virus.
The challengers in this case objected to covering PrEP, in particular, contending that the drug could “encourage homosexual behavior or intravenous drug use.”
The deal may not have much practical impact on most Americans. When the initial ruling from the district court came down in March, many health plans announced that they would not change their benefits.
Health plans typically have policies that span a full year, and it is unusual for them to change their members’ benefits in the middle of a contract. And insurers may be reluctant to take away a popular benefit that, in some cases, saves them money by preventing serious disease later on.
Matt Eyles, the president of AHIP, the trade group representing health insurers, said in a statement shortly after the initial ruling that there would be “no immediate disruption in care or coverage.”
The Blue Cross Blue Shield Association, which has health plans across the country, said in March that it would “strongly encourage their members to continue to access these services to promote their continued well-being.”
Nonprofit Health System Pauses Policy of Cutting Off Care for Patients in Debt
Allina Health, a large health system in the Midwest, had withheld care for patients who had $4,500 in medical bills.
Sarah Kliff and
Allina Health, a large nonprofit health system based in Minnesota, announced on Friday that it would stop withholding care from patients with outstanding medical debt as it “re-examines” its policy of cutting off services for those who have accrued at least $4,500 in outstanding bills.
The health system will now temporarily halt this practice but will not restore care for indebted patients who have already lost access.
Although Allina’s hospitals treated anyone in emergency rooms, other services were cut off for indebted patients, including children and those with chronic illnesses like diabetes and depression, The New York Times reported last week. Patients weren’t allowed back until they had paid off their debt entirely.
Allina’s chief executive, Lisa Shannon, called the move a “thoughtful pause” while the company re-examined the policy.
Dr. Matt Hoffman, an Allina primary care physician in Vadnais Heights, Minn., said he was encouraged by the change and hopeful that Allina would eventually make more significant reforms to how it treats indebted patients.
“I hope this is not just a temporary pause until the heat is off,” Dr. Hoffman said. “I hope they do the right thing, and reinstate the patients who were already terminated.”
Minnesota Public Radio first reported on the policy change.
Allina Health owns 13 hospitals and more than 90 clinics in Minnesota and Wisconsin. Thanks to its nonprofit status, Allina avoided roughly $266 million in state, local and federal taxes in 2020, according to the Lown Institute, a think tank that studies health care.
Attorney General Keith Ellison of Minnesota has asked patients to contact his office if they have been affected by Allina’s policies.
“I read The New York Times article with great concern and am reviewing it closely,” Mr. Ellison said in a statement to a local television station, KARE 11. “Allina is bound under the Hospital Agreement to refrain from aggressive billing practices and provide charity care when patients need and qualify for it, as all Minnesota hospitals are.”
https://www.nytimes.com/2023/06/09/health/allina-health-nonprofit-medical-debt.html be
Residents, fellows at Mass General Brigham vote to unionize
The move creates one of the largest unions of its kind in the country.
by Jessica Bartlett - Boston Globe - June 8, 2023
Medical residents and fellows at the state’s largest health system have voted to unionize, creating one of the largest unions of its kind in the country.
In a vote of 1,215 to 412, residents and fellows at multiple Mass General Brigham hospitals voted to join the Committee of Interns and Residents, or CIR, at the Service Employees International Union.
“It sends a pretty resounding message,” said Dr. Kayty Himmelstein, a member of the organizing committee for the union who said she cried tears of joy when she heard the news. “[I’m] excited to celebrate and to get to work negotiating our new contract.”
Approximately 75 percent of the more than 2,300 eligible members participated in the vote, including residents and fellows at Massachusetts General Hospital, Brigham and Women’s, Mass Eye and Ear, and Spaulding Rehabilitation Hospital. The results must be certified by the National Labor Relations Board to be final, a process expected to take place within the next week.
In a statement, Dr. Paul Anderson, interim chief academic officer at Mass General Brigham, said the mission of the organization remained unchanged, and the health system would work within the parameters that would be established by the union’s collective bargaining process.Approximately 75 percent of the more than 2,300 eligible members participated in the vote, including residents and fellows at Massachusetts General Hospital, Brigham and Women’s, Mass Eye and Ear, and Spaulding Rehabilitation Hospital. The results must be certified by the National Labor Relations Board to be final, a process expected to take place within the next week.
In a statement, Dr. Paul Anderson, interim chief academic officer at Mass General Brigham, said the mission of the organization remained unchanged, and the health system would work within the parameters that would be established by the union’s collective bargaining process.“As an organization dedicated to training the next great generation of caregivers, we are proud of the education that we provide to our residents and fellows, and we recognize the vital importance of the unique partnership between faculty and trainees in our institutions,” he said. “While we are disappointed with the outcome, this election is part of a continuing national trend among medical trainees seeking collective bargaining through union representation.”
The work of residents and fellows has always been demanding, often including 80-hour work weeks. But some say the pressures have escalated in recent years, with training for some doctors becoming longer, as more choose to sub-specialize in certain fields, including within surgery. Organizers hope to achieve better pay to accommodate the region’s high cost of living and financial support for child care. Other priorities include lower health insurance costs, compensation for supplies physicians use for work, and financial support for patients.
Residents and fellows have already begun to see changes, with the health system recently announcing it would provide 10 percent raises and $10,000 stipends to residents and fellows to accommodate the rising cost of living. The system said the increase was part of larger salary adjustments it began last year, but organizers credited the unionization effort.
The MGB move is only the latest nationwide. Since early 2021, CIR-SEIU membership has almost doubled from 17,000 to 30,000 today, as the pandemic put unprecedented strain on hospital staff. The union currently includes residents at Stanford Health Care, the University of California, San Francisco Medical Center, Montefiore Medical Center in New York, and Children’s National Medical Center in Washington, D.C.
In Massachusetts, Boston Medical Center and Cambridge Health Alliance have been unionized for several years. Residents and fellows at UMass Medical School unionized in 2021, winning their first contract last summer.
The unionization includes doctors in the post-medical school training period, which includes an initial residency that lasts between three and seven years, depending on specialty. A fellowship follows residency for some doctors and lasts from one to about three years.
The move to unionize began more than two years ago and has faced intense pushback from hospital leaders. Union organizers said hospital leadership adorned hospital walls with posters enumerating the reasons to vote no and circulated videos with similar messages. The health system additionally sent texts to employees’ cell phones and mailers to their homes.
Yet union organizers persisted, undertaking a grassroots effort to get out the vote largely through word of mouth. Groups coordinated coverage for colleagues as they took time out from their shifts to vote over the last week, and staff showed up to the polls despite the demands of the job. Some came in from parental leave; others showed up at 5:30 a.m. before operating room cases began.
“It’s an effort that reflects how much we care about this and how essential it is for our own wellbeing and patients,” Himmelstein said.
Participants said there was an “electric” atmosphere in the halls of Mass General on Thursday as the vote got underway. Dr. Sascha Murillo was walking in the hospital when she looked at her phone and saw dozens of messages from supporters about the win.
“I almost screamed in the hallway,” she said.
One hour after the vote was tallied, residents wearing union pins and wielding posters gathered in the CIR offices on Tremont Street to celebrate. Purple-painted walls matched “union strong” signs pinned up around the room.
For many, the unionization work was personal. Himmelstein, who has one more year in her fellowship, is nine months pregnant and has seen firsthand the challenge of juggling doctors’ appointments and managing the cost of future childcare.
“That added urgency for me, personally, to say, ‘We need a mechanism to advocate for ourselves to take care of ourselves and our families [so we can] focus on our patients while we’re at work,” she said.
https://www.bostonglobe.com/2023/06/08/metro/residents-fellows-mass-general-brigham-vote-unionize/
Why do the health economists keep getting it wrong?
For more than a decade, CMS and CBO consistently overestimated the growth in health care spending, which undermines efforts to spend more on health-related social needs
by Merrill Goozner - GoozNews - June 14, 2023
Earlier today, economists at the Centers for Medicare and Medicaid Services released their annual projection for health care spending over the next decade. After noting that spending fell to 17.4% of gross domestic product in 2022, which is about where it’s been for most of the past decade except during the Covid years, they predicted spending by Medicare, Medicaid, private insurance and other public and private entities would once again resume its upward trajectory this year and reach nearly 20% of GDP by 2031.
Hmmm. Where have I heard that before? I keep a file containing past CMS projections so it was fairly easy for me to check. The earliest article in my file dates from February 2008, when health care made up 16% of the overall economy. That year, CMS predicted spending would reach 20% of GDP by 2017.
Let’s go to the videotape. Seven years after President Obama and the Democratic Congress passed the the 2010 Affordable Care Act, which included numerous provisions aimed at reining in health care spending, it had only reached 17.7% of GDP.
The CMS prognosticators during the first year of the Trump administration didn’t do much better. In 2017, they predicted healthcare would reach nearly 20% of the economy by 2025. Now they’re saying it won’t reach that level until 2031.
To be fair, healthcare spending did spike to nearly 20% of GDP in 2020. But that was only because the pandemic dramatically slowed overall economic activity while the government poured cash into hospitals and physician offices to keep them running. It took only two years for it to fall back into the 17-18% of GDP range as the economy recovered and the stimulus was withdrawn.
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One could conduct a similar exercise with healthcare spending projections from the Congressional Budget Office. Fortunately, I don’t have to do the calculations because Sen. Sheldon Whitehouse (D-RI), chairman of the Senate Budget Committee, asked CBO director Phillip Swagel that very question.
Swagel replied in a letter earlier this year that CBO overestimated mandatory spending for health care in the 2010–2020 period by 9%. “Most of the overestimate for the Medicaid and Medicaid programs stemmed from an overestimate of spending per beneficiary, not an overestimate of the number of beneficiaries,” he wrote.
This systematic overestimation of future health care costs by government economists has far-reaching consequences. When CMS gets it wrong, organizational planners around the country are given a faulty notion of how much money will be flowing through the system, which could lead to a misallocation of resources.
When CBO gets it wrong, Congresspersons get a faulty notion of what resources are available to spend on other programs. It also feeds the GOP’s hysteria around balancing the budget, which undermines political support for other social programs, including those that would actually improve the health of the nation.
Does greater spending on health matter?
I’m not saying we shouldn’t care how much of society’s resources healthcare consumes. Let’s look at the question first from the consumer/taxpayer/employee perspective.
Health care is a social good that we’d all rather avoid. No one wants to get sick. But sickness is part of the human condition and a drain on society. That’s why every country devotes a substantial share of its economy to preventing and curing illness, although no country on earth comes even close to what the U.S. spends.
Yet the U.S. gets far less for its spending than other countries. Longevity has been falling for several years. Our infant and maternal mortality rates are a national disgrace. Nearly 30 million of our fellow citizens do not have health insurance, the only advanced industrial country without universal coverage.
And, it is not as if we’re consuming more services. We don’t. As health care consumers, we’re paying the highest prices in the world for an inferior product. We can transplant organs and cure rare diseases, but are incapable of responding to a public health crisis (1.16 million dead from Covid, by far the highest number in the world). Nor have we managed to address the chronic conditions that are driving the downward spiral in longevity like uncontrolled obesity, hypertension and substance abuse.
Spending more on health care isn’t good for economic growth except in the narrowest sense. The sector employs tens of millions. Indeed, it has become the biggest employer in many cities and town. But that is economic activity that could be directed elsewhere.
Why do I say that? It is important to remember that everyone pays for health care through taxes and wages. Taxes pay for Medicare and Medicaid. Your wages pay for employer-provided health insurance, which is money that could otherwise go into your paycheck or into retirement savings or other benefits. Money spent on health care is money that can’t go to pay for other good and services, which very often are the very items that would create a healthier society like better housing, better food and greater economic security.
It is possible that health care spending in the coming decade will grow to nearly 20% of GDP as a share of overall GDP. The demographics of an aging society are real. Most drug prices, especially those new to market, will continue to rise given the power of Big Pharma. The share of resources flowing to hospitals and physician practices will remain steady.
The result, should that come to pass, will be a health care sector that continues to consume a disproportionate share of the nation’s resources while the broader society’s health continues to deteriorate. What I would rather see is a society where the health care sector’s share of the nation’s resources starts to shrink; we spend more on the social services and social goods that promote good health; and people once again are living longer, happier and healthier lives.
