Protests for Gun Safety … & Health Care Justice

Summary: Following another mass school shooting, a prominent GOP former governor calls for ongoing protests in the street to force real change. It worked in the Civil Rights Movement, and it can again. Let’s demand gun safety … and, while we’re out there, health care justice via Medicare for All.

Interview of former Gov. John Kasich (R, Ohio) after tragic school shooting in Nashville
March 28, 2023
Andrea Mitchell Reports

If Americans don’t protest gun violence, politicians will continue to ‘look the other way’

Gov. Kasich:

Until people go into the streets and protest, we’re not going to see changes. In my state, had I been able to get five thousand, ten thousand people on the lawns of the state house, politicians would have passed what we wanted. I couldn’t get them mobilized. I was reading this morning about the Montgomery bus boycott. You realize that took over one year for the Supreme Court ultimately to act to end discrimination on transportation. If you don’t have the people rising up, like they did with civil rights, like they did to end the Vietnam war, if you don’t have that, the politicians are going to keep passing the buck. They’re going to listen to one group of people, and, frankly, if in fact we can have the kind of massive outpourings that we have seen in this country consistent about saving our children at this point and so many other tragic accidents then you put the real pressure on the politicians to do things that we all know that we can do while still preserving the right of the second amendment. Things can be done that can provide a safer environment for all of us in this country and most particularly our children. Without the protest, Andrea, I think we’re going to keep doing… 19 incidents, 19 incidents in school shootings this year! This is sick! I heard the lady talking about all the people she visited, God bless her, she along with all of the other people who have experienced this tragedy personally has to figure out a way to mobilize all of us to stand up and say. “Enough!”

Now what I said about those women down in Montgomery, they just kept marching. They just kept doing everything they could, and that’s what it’s going to take here. If we don’t have people to begin to get into the streets and say, “Enough of this!”… the women who were so worried about all the children… the men who say this is my family… we all have to mobilize. Without it, the politicians are going to look the other way. And it’s not going to happen in a week or two. It has to be ongoing in order to get this changed. That’s my opinion on it because I sat there trying to get things done, and I was frustrated the whole time. I did what I could with executive orders, as the president has done, but there’s a limit to it. We have to get legislative action with common sense proposals that can really make a difference.

Comment by: Don McCanne

Now that guns have replaced auto accidents as the number one cause of deaths in children, isn’t it about time we really did something about it? We haven’t acted, with Democrats blaming Republicans for inaction and Republicans blaming Democrats for attacking their second amendment rights. But here we have one of the more prominent Republicans in the nation saying , “Enough!”

Mr. Kasich makes it clear that we cannot expect a responsible response to these tragedies from the politicians, as our nation’s political history has demonstrated. But he has much more faith in us, the people. All we have to do is to go into the streets, in mass, and protest. We need to march, and keep on marching. The politicians who are looking the other way will no longer be able to do so if we stay in their faces.

Our children….
    are being slaughtered by gun violence….
    and the politicians have failed us
To the streets everyone!

But wait….

We are spending more on health care than any other nation, yet we tolerate more suffering in children and others through mediocrity in health care and through the profound prevalence of poverty. While we’re demonstrating against violence in our children, shouldn’t we be simultaneously protesting this form of violence as well, violence that is quantitatively much greater and often just as tragic.

Yes. To the streets….  “No More Guns” at the top of our placards, but “Health Care Justice for All” below that.


Legislation to Advance California Single Payer Process

Summary: A proposed law in the California Senate would instruct state officials to engage with the federal government on approvals and coordination for a state single payer bill. This is an important complement to a single payer bill in the Assembly.

New bill would pressure Newsom to speed up work on single-payer health care
San Francisco Chronicle
March 21, 2023
By Sophia Bollag

Gov. Gavin Newsom would face new deadlines on his administration’s work to revamp the state’s health care system under a bill unveiled Tuesday in the state Legislature.

Newsom, a Democrat, has said for years that he supports creating a government-run health system in California, including while campaigning for governor, but since taking office has not endorsed specific legislation to do so.

Early last year, when Newsom was asked if he supported a bill to create a universal, government-run health care system in California, he dodged the question, saying he was waiting for a report from a state commission studying the issue. That report came out last April, and endorsed a vast overhaul of California’s health system.

Transitioning the state from a system where private health insurance companies control much of the market to one run by the state would be a huge undertaking, one that would require permission from the federal government in the form of a waiver. On his first day in office, Newsom announced that he was pursuing such a waiver. More than four years later, California still does not have one.

A bill Sen. Scott Wiener, D-San Francisco, announced Tuesday would impose deadlines on the administration and give the Legislature a role in the process of securing a waiver. It doesn’t explicitly call for a single-payer health care system, and instead uses the term “unified financing,” which is the language endorsed by the report from the state commission.

Advocates of “single payer” generally endorse a system that is government-run, and where the state is the sole entity paying for health care. A “unified financing” system could take that form, according to the report, but could also include a role for private insurance companies that fiercely oppose a single-payer system that would put them out of business. The report does, however, call for distinctions between private insurance and government plans to be dissolved.

Wiener’s bill, SB770, would require Newsom’s health secretary to brief the Legislature on the status of its work to secure a federal waiver every few months, and to produce a formal report on the administration’s progress and plans by June 2024. It would also give legislative leaders power to appoint people to a group advising the administration’s work.

Comment by: Michael Lighty

With the introduction last week of California Senate Bill 770, advocates for health justice opened a new path to achieve guaranteed healthcare for all based on single payer financing.

Rather than propose a comprehensive policy bill developed by a few single payer experts (an essential component of our work but an approach that has not succeeded politically after numerous attempts), SB 770 seeks to engage health justice supporters of all stripes to collaborate on a proposal to be presented to the California Legislature under a definite timeline.

SB 770 is part of the newly launched Healthy California for All Now campaign. Our goal is to guarantee equitable healthcare to all California residents that provides better care at less cost for families, through public financing.

The campaign builds on the positive momentum created by the Healthy California for All Commission, which concluded that single payer (what they call “unified financing”) could save at least 4,000 lives annually and $158 billion in 2031. The Commission gave official approval for a program which it summarized as:

  • All Californians will be entitled to receive a standard package of health care services;
  • This package could include Long Term Care Support and Services, which would relieve huge and growing burdens that are falling on millions of families; 
  • Entitlement will not vary by age, employment status, disability status, income, immigration status, or other characteristics; and
  • Distinctions among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage will be eliminated within the system of unified financing.

Those findings are incorporated into SB 770 as the first step in a process which directs the Secretary of the California Health and Human Services (HHS) Agency to:

  • Pursue waiver discussions with the federal Center for Medicare and Medicaid Services (CMS) to facilitate the creation of a unified healthcare financing system;
  • Establish a Waiver Development Workgroup of diverse healthcare system stakeholders appointed by the Governor, Speaker of the Assembly, and President Pro Tempore of the Senate; 
  • Provide quarterly reports to the chairs of the Assembly and Senate Health Committees on the status and outcomes of waiver discussions with the federal government and on workgroup progress;
  • Submit a complete set of recommendations regarding the elements to be included in a formal waiver application, as specified, by no later than June 1, 2024

Single payer advocates are building an outreach and public education campaign to bring into legislative discussions health justice advocates from varied contexts: labor, expanding coverage for undocumented residents, reforming Medi-Cal, and rate-setting for health systems. This marks a critical broadening of our advocacy base. It will foster decisions on unsettled key policy and financing issues from the Healthy California for All Commission that the Legislature will support.

SB 770 and CalCare (AB 1690), the comprehensive single payer bill sponsored by the California Nurses Association, are on complementary tracks. The first legislative goal would be passing the collaborative engagement and advisory process in SB 770, to be followed by consideration of a comprehensive single-payer program, including the proposals in CalCare, which is slated to be considered in 2024.

It’s vital that advocates support the process. We must repeatedly highlight the broad and deep political support for single payer, and contribute to the resolution of key political, legal, and technical issues to support state single payer. SB 770 provides an essential opportunity and a path to guaranteed healthcare.

We have an historic opportunity to achieve political success for single payer – let’s seize the moment!


Mr. Lighty is President, Healthy California Now.


America’s Poverty Disgrace

Summary: Matthew Desmond is shaking up how we think about poverty in America: far too prevalent and persistent, fueled by structural exploitation in housing, labor, and financial services. And solvable with an affordable level of resources. Single payer also has a crucial role to play.

America Is in a Disgraced Class of Its Own
New York Times
March 16, 2023
By Matthew Desmond

(bolding by HJM)

The United States has a poverty problem.

A third of the country’s people live in households making less than $55,000. Many are not officially counted among the poor, but there is plenty of economic hardship above the poverty line. And plenty far below it as well. According to the Supplemental Poverty Measure, which accounts for government aid and living expenses, more than one in 25 people in America 65 or older lived in deep poverty in 2021, meaning that they’d have to, at minimum, double their incomes just to reach the poverty line.

Programs like housing assistance and food stamps are effective and essential, protecting millions of families from hunger and homelessness each year. But the United States devotes far fewer resources to these programs, as a share of its gross domestic product, than other rich democracies, which places America in a disgraced class of its own on the world stage.

On the eve of the Covid pandemic, in 2019, our child poverty rate was roughly double that of several peer nations, including Canada, South Korea and Germany. Anyone who has visited these countries can plainly see the difference, can experience what it might be like to live in a country without widespread public decay. When abroad, I have on several occasions heard Europeans use the phrase “American-style deprivation.”

Poverty … is experienced as an exhausting piling on of problems. Poverty is chronic pain, on top of tooth rot, on top of debt collector harassment, on top of the nauseating fear of eviction. It is the suffocation of your talents and your dreams. It is death come early and often. From 2001 to 2014, the richest women in America gained almost three years of life while the poorest gained just 15 days. Far from a line, poverty is a tight knot of humiliations and agonies, and its persistence in American life should shame us.

All the more so because we clearly have the resources and know-how to effectively end it. The bold relief issued by the federal government during the pandemic — especially expanded child tax credits, unemployment insurance and emergency rental assistance — plunged child poverty and evictions to record lows and powered a swift economic recovery. “I don’t think we have ever seen a policy have as much impact as quickly as the child tax credit in 2021,” Dorian Warren, a co-president of Community Change, a national organization aimed at empowering low-income people, told me. “In six months — six months — we reduced child poverty almost by half. We know how to do this.”

We do — but predictably, some Americans with well-fed and well-housed families complained that the country could no longer afford investing so deeply in its children. At best, this was a breathtaking failure of moral imagination; at worst, it was a selfish, harmful lie.

We could fund powerful antipoverty programs through sensible tax reform and enforcement. A recent study estimates that collecting all unpaid federal income taxes from the top 1 percent — not raising their taxes, mind you, just putting an end to their tax evasion — would add $175 billion a year to the public purse. That’s enough to more than double federal investment in affordable housing or to re-establish the expanded child tax credit. In fact, an additional $175 billion a year is almost enough to lift everyone out of poverty altogether.

The hard part isn’t designing effective antipoverty policies or figuring out how to pay for them. The hard part is ending our addiction to poverty.

Poverty persists in America because many of us benefit from it. We enjoy cheap goods and services and plump returns on our investments, even as they often require a kind of human sacrifice in the form of worker maltreatment. We defend lavish tax breaks that accrue to wealthy Americans, starving antipoverty initiatives. And we build and defend exclusive communities, shutting out the poor and forcing them to live in neighborhoods of concentrated disadvantage.

Most Americans — liberals and conservatives alike — now believe people are poor because “they have faced more obstacles in life,” not because of a moral failing. Long overdue, however, is a reckoning with the fact that many of us help to create and uphold those obstacles through the collective moral failing of enriching ourselves by impoverishing others. Poverty isn’t just a failure of public policy. It’s a failure of public virtue.

To break this cycle, we must commit to becoming poverty abolitionists.

Like abolitionist movements against slavery or mass incarceration, abolitionism views poverty not as a routine or inevitable social ill but as an abomination that can no longer be tolerated. And poverty abolitionism shares with other abolitionist movements the conviction that profiting from another’s pain corrupts us all.

Ending poverty in America will require both short- and long-term solutions: strategies that stem the bleeding now, alongside more enduring interventions that target the disease and don’t just treat the symptoms.

When the Johnson administration launched “an unconditional war on poverty in America” in 1964, it wasn’t just lofty rhetoric. It set a deadline. Sargent Shriver, the director of the Office of Economic Opportunity, announced that “the target date for ending poverty in this land” would be 1976, the bicentennial. “We once had ambitions about poverty abolitionism,” Dorian Warren reminded me, and we can rekindle that sense of urgency.

We can also disrupt all the quotidian ways we normalize the status quo. It is commonplace for privileged Americans to gripe about taxes. But doing so ignores how the country’s welfare state does much more to subsidize affluence — with tax breaks for college savings accounts, wealth transfers and more — than to alleviate poverty.

Today, as then, the best hope we have of ending poverty is to bind ourselves together and demand this of our country. A mass movement for economic justice is necessary. One led by those who have had enough is stirring. We can join them, no matter our lot in life.

Why Poverty Persists in America
New York Times Magazine
March 9, 2023
By Matthew Desmond

On the problem of poverty, though, there has been no real improvement — just a long stasis. As estimated by the federal government’s poverty line, 12.6 percent of the U.S. population was poor in 1970; two decades later, it was 13.5 percent; in 2010, it was 15.1 percent; and in 2019, it was 10.5 percent. To graph the share of Americans living in poverty over the past half-century amounts to drawing a line that resembles gently rolling hills.

The primary reason for our stalled progress on poverty reduction has to do with the fact that we have not confronted the unrelenting exploitation of the poor in the labor, housing and financial markets. … When we are underpaid relative to the value of what we produce, we experience labor exploitation; when we are overcharged relative to the value of something we purchase, we experience consumer exploitation. … When we don’t own property or can’t access credit, we become dependent on people who do and can, which in turn invites exploitation, because a bad deal for you is a good deal for me.

Those who have amassed the most power and capital bear the most responsibility for America’s vast poverty: political elites who have utterly failed low-income Americans over the past half-century; corporate bosses who have spent and schemed to prioritize profits over families; lobbyists blocking the will of the American people with their self-serving interests; property owners who have exiled the poor from entire cities and fueled the affordable-housing crisis.

Living our daily lives in ways that express solidarity with the poor could mean we pay more; anti-exploitative investing could dampen our stock portfolios. By acknowledging those costs, we acknowledge our complicity. Unwinding ourselves from our neighbors’ deprivation and refusing to live as enemies of the poor will require us to pay a price. It’s the price of our restored humanity and renewed country.

Comment by: Jim Kahn & Don McCanne

How do we make the poor poor? We exploit them in the labor market, the housing market, and the financial market, leaving us better off. We prioritize subsidizing affluence over the alleviation of poverty, taking good care of our billionaires. We create prosperous and exclusive communities with concentrated riches leaving other communities with concentrated despair. We, the citizens of the richest nation on earth, can and should put an end to this.

Mr. Desmond, a sociologist at Princeton, just published “Poverty, by America”. He tells this story well and generally quite comprehensively, recognizing the manifold ways that we stack the deck against the poor. We should take to heart his analysis and appeal for action.

However, on health care he tells only part of the story, and misses the ultimate solution. He mentions the tax benefit of employer-sponsored health plans, which is of course targeted to those in solid jobs with health insurance.

But there are numerous other ways that the health system afflicts the poor. For starters, most of the tens of millions of uninsured are poor or near-poor. For those on Medicaid, the reliance on private managed care companies shifts money for care into corporate profits. The valuable surge in Medicaid coverage since 2020 is now reversing with reinstatement of stricter pre-COVID eligibility requirements. The growth of high-deductible health plans over 20 years is causing huge barriers to care and driving rises in medical debt and bankruptcy. Health savings accounts that can be transferred to tax-protected retirement funds favor the rich and healthy. And the entire messy financing system removes more than $600 billion per year from care to administrative waste, massive shareholder profits (at insurers, providers, and pharm), and sky-high CEO salaries.

No doubt about it, our health system is contributing to poverty and its deprivation and anxiety. Single payer would solve these problems. Savings from single payer, about $200 billion per year, would be enough to end poverty (per Mr. Desmond’s numbers). And, unlike some of his other poverty strategies (such as reducing tax breaks on home mortgages), single payer would benefit the broad middle class, not hurt them.

Let’s end poverty and the exploitation that drives it, in housing, labor, finance … and health care!


Retailers Buying Up Health Care Delivery

Summary: Major general retailers, like Amazon and Walmart, are acquiring large medical care delivery networks. And they’re linking to Medicare Advantage, a huge cash cow for insurers and linked providers. We need single payer to interrupt the corporate takeover.

How major retailers are trying to change how America consumes health care
March 8, 2023
By Tina Reed

Amazon, Walmart, CVS, Dollar General and other big retailers are elbowing their way into health care delivery, pushing a customized consumer experience driven by digital health products.

At its core, these companies are pulling together different tech-enabled services – urgent, primary, more and specialty care, pharmacy, and, in some cases, full integration with an insurer. 

But the retailers’ forays are prompting growing anti-trust and privacy concerns, as well as fears of further erosion of the doctor patient relationship once considered central to coordinated care.

Amazon brought in an on-demand virtual care services platform, more than 125 locations and a piece of the Medicare Advantage business (with the company’s $3.9 billion acquisition of concierge medicine provider One Medical).

Best Buy Health launched a hospital-at-home program with North Carolina-based Atrium Health.

Walmart announced last week that it plans to nearly double the footprint of its in-store clinics. In the fall, Walmart also inked a 10-year Medicare Advantage deal with UnitedHealth Group.

In January, CVS Health announced a plan to buy Oak Street Health, a primary care group focused on Medicare patients. The pharmacy giant already owns insurer Aetna, pharmacy benefit manager CVS-Caremark, home health company Signify Health and health care service brands MinuteClinic and HealthHUB.

Also in January, Walgreen-backed primary care company VillageMD, scooped up more primary, specialty and urgent care investments augmenting plans to open more than 500 full-service doctors’ offices in Walgreens locations.

Other companies like Rite Aid, Albertsons, and Dollar General have launched programs in health care delivery.

Amazon, CVS and Walmart have made some of the most consequential moves by combining their massive retail footprints with assets like primary or urgent care sites, pharmacies, and some sort of relationship with insurers.

“They’re all acquiring every piece of medicine,” Robert Pearl, a Stanford University professor and former CEO of The Permanente Medical Group, told Axios.

In recent months, retailers are investing in end-to-end primary care. “That’s what gets me increasingly excited about their role because there’s only so much you can do as the urgent care provider and much much more you can do when you have that longitudinal relationship between the doctor and a patient over time,” said Jacob Effron, a principal at Redpoint Ventures.

Each of these businesses are also clearly eyeing a clearly lucrative segment of health care: Medicare Advantage.

Comment by: Don McCanne

It appears that the capture of the health care delivery system by private equity is moving along quite smartly. That is coordinated with private insurance, especially Medicare Advantage plans. The result is a massive cash cow, the “money machine” as we’ve discussed often in HJM.

Two significant trends in this regard have been not only the increase in private Medicare Advantage plans but also the rising recognition that single payer Medicare for All may be the answer to the financial burden that has been created by uninsurance, underinsurance, deductibles, copayments, coinsurance, and disallowed services.

The problem is that they seem to be setting the stage for privatized Medicare Advantage for All, combining the worst of the medical industrial complex. This likely will move even more of our health care dollars into the hands of the uber-capitalists, as Bernie Sanders is explaining on his current book tour, but it will leave care for patients and their providers underfunded, making the wealthy wealthier and the rest of us mired in mediocrity, at best.

No. We don’t want the private sector proposals designed to create more wealth for the wealthy. We want reform designed to provide health services for all of us. But we are rapidly heading in the wrong direction. We need to enact and implement a well-designed single payer Medicare for All, and we need to do it IMMEDIATELY! The billionaires are already swarming.


UK National Health Service Woes Due to Privatization & Funding Cuts

Summary: The UK national health service has been a highly regarded and popular model of public financing and ownership of health services. That is, until the British government fostered privatization and, during Conservative rule, imposed austerity budgets. It can still be saved.

You Don’t Have to Be a Doctor to Know How Much Trouble the N.H.S. Is In
The New York Times
March 17, 2023
By Allyson Pollock and Peter Roderick

You don’t have to work in a hospital to know that Britain’s N.H.S. is in the most serious crisis of its history; you just have to be injured, or ill. And hundreds of thousands of people have had a doctor’s referral for outpatient care at a hospital rejected because there are no available appointments — they are simply bounced back to the doctor to begin the process again.

That the flagship health care service of one of the wealthiest countries in the world is in such a state is shocking, but not without explanation. Decades of marketization, 10 years of Conservative austerity and a pandemic have hollowed out the N.H.S. so much that people who can afford to, and increasingly those who can’t, are having to pay for health care.

A two-tier system with more and more in common with American health care is taking shape. It’s not working, and we’ll soon be at the point where it’s too late to do anything about it.

The damage to the N.H.S. was inflicted in three main waves.

In the late 1980s and early ’90s, a Conservative government introduced the internal market and closed long-stay hospitals — where care was free — under the euphemistic banner of “care in the community.” Private nursing homes backed by equity investors took over provision for older people, and care became chargeable and means-tested.

In the late 1990s and early 2000s, Labour, under Tony Blair, built dozens of new hospitals with money from partnerships with private investors.

In 2010, the Conservatives, back in power — alongside the Liberal Democrats until 2015 — embarked on a decade of austerity.

The cumulative effect was devastating.

But people are also tired of waiting — or not able to wait — and more and more are paying for private treatment.

People are reportedly taking out loans to pay for operations and, in a development that will be familiar to Americans but is something quite new in Britain, more and more people are turning to GoFundMe to raise money for medical treatment.

The government has done plenty to encourage this shift: In 2012, the Conservatives increased the cap on what percentage of an N.H.S. hospital’s income could come from treating private patients to 49 percent.

What we do know is Britons who want to use the N.H.S. are finding it increasingly hard to do so.

The N.H.S. as Britons have known it — accessible, free at the point of use, cherished — is becoming something else. But as long as there are still people willing to fight for it, it’s not too late to save it.

Allyson Pollock in 2014 video raising alarm on NHS privatization:

From here.

Comment by: Don McCanne & Jim Kahn

For many decades, those of us in the policy community interested in health care justice for all have greatly admired the British National Health Service as it was founded as a cherished health care system, accessible to all, and free at the point of service.

In the meantime, we established a public insurance program for seniors – Medicare – and many of us have supported policies to improve that program and expand it to include everyone. Instead, we are well on the path to total privatization of the Medicare program as it has deteriorated. Uninsurance and underinsurance permeate our system, costs have gone up, medical debt and personal bankruptcy are increasing, many are left without the health care they should have, and the increased spending of our health care dollars has been moving into the coffers of the billionaires. The government has not been listening to us in the policy community who can provide the solutions to our health care injustices.

Today’s article tells a really sad story because we should have been learning from the British model and applying it to our system. The British, of course, had demonstrated how much more effective the government was than the private sector, whereas we increased the role of the private sector resulting in the higher costs and deterioration of our system.

A co-author of today’s article, Allyson Pollock, has been a leader in the British policy community, and has issued warnings that they should not follow privatization schemes such as we have in America. Their political leaders did not listen either. As seen in the figure above, the needed growth in health spending as % of GDP was reversed starting in 2009, starving the system. Just as in the United States, it was not just the conservatives, but it was the neoliberals as well, as they followed a path more like ours instead of us following theirs. This brief report shows what a disaster it has been.



How Medicare Advantage Distorts Clinical Outcome Data

Summary: Two studies reveal how Medicare Advantage plans distort comparisons with Traditional Medicare on inpatient and emergency visit rates, which represent clinical deterioration. A study done by MA employees is biased by massive diagnostic upcoding of MA enrollees. A study by university researchers reveals how inpatient admissions fall while emergency visits rise even more. Properly examined, MA has worse outcomes.

Comparison of Care Quality Metrics in 2-Sided Risk Medicare Advantage vs Fee-for-Service Medicare Programs
JAMA Network Open
December 12, 2022
By Kenneth Cohen et al

Findings In this cohort study of 316 312 individuals, physicians in a 2-sided risk Medicare Advantage model provided care of higher quality and efficiency compared with those practicing in a fee-for-service Medicare program in all 8 metrics measured. [NB – HJM doesn’t believe these findings … see comment]

Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare
JAMA Health Forum
February 24, 2023
By Adam L. Beckman et al

Importance Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care−sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges.

Objective To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare.

Results Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44) and observation stays (RR, 2.38) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30).

Comment by: Jim Kahn

I’m a huge believer in the value of “health services research”. We need formal quantitative analyses of the effects of insurance status and other factors on measures – like hospitalization – that reflect clinical and financial outcomes. And I’ve seen enough studies over the decades to know that extracting legitimate conclusions from these studies is challenging, due to the complexity of the medical world and due to the risk of shoddy (often biased) research.

Both complexity and bias are in evidence with these two studies that compare hospitalization rates in Medicare Advantage (MA) vs Traditional Medicare (TM). One, done by UnitedHealth Group employees, is profoundly biased. The other, by respected academic researchers, elucidates what’s really happening with hospital and emergency stays.

The industry study (Cohen et al) examines several inpatient and emergency outcomes. Its core problem is huge diagnostic upcoding of the MA beneficiaries. As shown in Table 1, the prevalence of recorded serious diagnoses is twice as high for MA plans as for TM – despite the fact that MA enrollees are known to be healthier than TM enrollees. Why does this matter? Because several of the key statistical analyses are adjusted for the misleading extra diagnoses. If the MA beneficiaries seem sicker than they really are, it makes MA plan outcomes look better. Thus, key results are fallacious, most strikingly for COPD and heart attack / stroke. If the MA population was properly represented as healthier than the TM population, TM would probably have looked better across the board. (The paper is also incompletely and confusingly reported, which challenges sorting out all the details.)

An important quick detour: Rick Gilfillan, Don Berwick, and others analyzed the financial implications of this huge diagnostic upcoding, finding that it would lead to a 34% overpayment to MA as compared with TM. This confirms their prior “money machine” analyses discussed here, buttressing the argument that MA is shifting public funds to private shareholders.

The academic study (Beckman et al) is a model of conceptual clarity, sophisticated statistics, and excellent reporting. It adjusts (in several ways) for diagnostic upcoding. And it finds that an apparent decrease in hospitalization rates in MA is more than offset by increases in emergency department discharges and “observation” visits. In other words, for medical conditions amenable to good ambulatory care, overall MA does worse than TM. Why would these clinical episodes shift from inpatient to emergency department only? An obvious concern is that MA plans are denying authorizations for inpatient admission. Is that inferior clinical care? Impossible to say, but that’s a real concern. In any case, this excellent research clarifies that MA claims of lower hospitalization rates are misleading at best.

When it comes to health services research (perhaps even more than medical research in general), coupled with financial interests, the adage must be, “Buyer beware”. We at HJM strive to be your docent in this world.


Bernie Sanders Takes on Capitalism

Summary: Bernie Sanders is a beacon of clarity for the pursuit of human welfare. In his new book, Bernie highlights how very American it is to confront and change the uber-capitalism that afflicts our nation. Health care is the poster child of this struggle.

It’s OK To Be Angry About Capitalism
Crown Publishing
February 2023
By Bernie Sanders

Capitalism is the problem

Some people think that it’s “un-American” to ask hard questions about where we are as a nation, and where we’re heading. I don’t. To my view, there is nothing more American than questioning the systems that have failed us and demanding the changes we need in order to create the kind of society that we and future generations deserve.

Here is the simple, straightforward reality: The uber-capitalist economic system that has taken hold in the United States in recent years, propelled by uncontrollable greed and contempt for human decency, is not merely unjust. It is grossly immoral.

We need to confront that immorality. Boldly. Bluntly. Without apology. It is only then that we can begin to transform a system that is rigged against a vast majority of Americans and is destroying millions of lives.

Confronting that reality and mobilizing people to bring about the transformational change we need is not easy. That’s why I’ve written this book. We need not only to understand the powerful forces that hold us down today but, equally important, to have a vision as to where we want to be in the future.

Health care is a human right. Period.

I’m not talking about expanding the Affordable Care Act and providing more subsidies. To the insurance companies that maintain – and profit immensely from – an incredibly wasteful, bureaucratic, and cruel system. I’m talking about all Americans being able to walk into a doctor’s office or a hospital and get all of the health care they need with no out-of-pocket costs. I’m talking about replacing a wildly inefficient system in which we spend over $12,000 per person every year, almost twice as much as any other major country, while 85 million Americans are uninsured or underinsured and sixty thousand a year die because they don’t get to a doctor on time.

I’m talking about a Medicare For All system.

The establishment – the corporate world, the politicians, and the media – tells us that this is a “radical” idea. Totally impractical. It just can’t be done. It’s not even worth discussing – not in the halls of Congress, not on radio or TV, not in most medical schools.

Really? If this is such an impractical idea then why, in one form or another, has every other major country on earth already accomplished the goal of providing health care for all – and at a fraction of the cost that we’re paying? On a recent trip to London, I chatted with a Conservative member of Parliament who told me how proud she was of the free health care the government provided. That’s a Conservative speaking!

Will Medicare For All solve all our health care problems? Of course not. But think about the profound impact it will have when the burden of devastating health care expenses is lifted from the shoulders of working families. Think of what it will mean when no American hesitates to walk into a doctor’s office because of the cost. Think about what it will mean when no one goes bankrupt because they have a serious illness.


Real Politics Starts with Organizing

One of the important lessons I have learned from history is that real change never takes place from the top down. It always comes from the bottom up. Fundamental change is not going to happen because of fundraisers at wealthy people’s homes. It’s not going to happen because of clever TV ads or the scheming of inside-the-Beltway political consultants and pollsters. It’s going to happen when millions stand up and demand that change.

Real politics is about rejecting the establishment’s determination as to what is “possible,” “achievable,” and “acceptable.” It is about declaring, unapologetically, that we will not allow American oligarchs and their legions of publicists to shape our vision as to the kind of world we want to live in. That’s our decision.

Bernie Sanders Discusses “It’s OK To Be Angry About Capitalism”
Face the Nation (26 m)
Southbank Center (for British audience; 1 h 45 m)

Comment by: Don McCanne & Jim Kahn

Who should not have access to health care? Many of us believe, like Bernie, everyone should be included.

In this important new book, Bernie updates and elaborates on his vision for a just and generous America, one in which we prioritize fundamental human needs – like health – over capitalist profiteering. All other wealthy countries provide comprehensive health care, spending far less than we do with our expensively convoluted system.

Let’s ask the corporate and government oligarchs who are responsible for the policies that create the barriers to care whom they believe should be left out of the system, even though we could very easily afford to cover everyone. Indeed, let’s turn the tables: invite them to negotiate the portion corporations and shareholders get in a single payer Medicare for All program. (Hint: not much!)