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Let’s Not Mourn the Death of the Public Option

The health insurance public option might be fizzling. The left is OK with that., NBC News, June 5, 2021, By Benjy Sarlin and Sahil Kapur

“A decade later, Joe Biden campaigned on making the public option a reality, but so far, he’s done little to get Congress to enact one. Instead of outrage, influential progressives seem to be OK watching the promise go unfilled, preferring to pursue universal health care through other means, like expanding Medicare eligibility.

Elected officials, health care activists and experts who spoke to NBC News said the issue has fallen off the national radar and will be difficult to revive without a major push by the White House.

Responding to the pandemic has consumed much of Biden’s attention in his first months in office. And beyond that, he has a long list of agenda items to get to first, including many that are popular with progressives.

“I don’t think there’s a dynamic where we see it at the center of a political fight again,” said Alex Lawson, the executive director of the left-leaning group Social Security Works.”

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Comment by Eagan Kemp

No one should mourn the end of a push for a public option in health care. It was never the solution the country needed for health reform. 

The risks inherent in a public option completely overwhelm any potential gains. Given the rapid rise in for-profit companies gaming Medicare through Medicare Advantage, there is no reason to believe that a public option would be any different when it comes to insurers dumping patients with high health needs, while retaining patients that are profitable. If the for-profit insurers can cherry-pick healthier Americans through seemingly more favorable plans (while they are healthy), then the public option could become overly burdened and unsustainable. 

In addition, a public option would have just been one more area of added complexity in our already fragmented health care system, which already struggled to respond to the COVID-19 crisis. 

A public option would also further entrench the power of for-profit insurers. And the massive administrative waste of private insurance companies would continue under a public option, whereas under Medicare for All the reduction in administrative savings would be more than $500 billion a year. 

In terms of political feasibility, there is the perception that less comprehensive reforms could have an easier chance of passing. However, the companies that profit off our healthcare system have shown they are just as opposed to the most basic public option proposal as they are to Medicare for All. Both the Partnership for America’s Health Care Future and Coalition Against Socialized Medicine—which strongly oppose Medicare for All as well as a public option —have shown they will not compromise on behalf of their corporate backers. 

While proponents of a public option may try to make their proposal sound “reasonable,” it wouldn’t come close to matching Medicare for All. Whether it is savings for families, savings for the country or ensuring that everyone in the country has guaranteed access to medically necessary care, only Medicare for All would create the health care system we need.

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Public Insurers Provide Better Access, Financial Protection, & Satisfaction Than Private Insurers

Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US, JAMA Network Open, June 1, 2021, By Charlie M. Wray, Meena Khare, Salomeh Keyhani

Introduction: In the past decade, health insurance expansion has been a major aspect of health care reform in the US, with the Patient Protection and Affordable Care Act (ACA) increasing coverage to more than 20 million US adults.

We used the Behavioral Risk Factor Surveillance System (BRFSS) to compare experiences related to access to care, costs of care, and satisfaction with care among the 5 major forms of health insurance coverage (private employer–sponsored insurance, private individually purchased insurance, Medicare, Medicaid, and Veterans Health Administration [VHA] or military coverage) after accounting for respondents’ underlying health.

Results: …Compared with those covered by Medicare, individuals with employer-sponsored insurance were less likely to report having a personal physician (odds ratio [OR], 0.52; 95% CI, 0.48-0.57) and were more likely to report instability in insurance coverage (OR, 1.54; 95% CI, 1.30-1.83), difficulty seeing a physician because of costs (OR, 2.00; 95% CI, 1.77-2.27), not taking medication because of costs (OR, 1.44; 95% CI, 1.27-1.62), and having medical debt (OR, 2.92; 95% CI, 2.69-3.17). Compared with those covered by Medicare, individuals with employer-sponsored insurance were less satisfied with their care (OR, 0.60; 95% CI, 0.56-0.64)…

Conclusions and Relevance: In this survey study, individuals with private insurance were more likely to report poor access to care, higher costs of care, and less satisfaction with care compared with individuals covered by publicly sponsored insurance programs. These findings suggest that public health insurance options may provide more cost-effective care than private options.

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Comment by Don McCanne

How many times do we have to say it? Public health insurance is designed to make health care accessible and affordable for the people. Private health insurance is designed to make a profit for the insurers. The policies used in the design of the various insurance products are selected on the basis of the desired results. Access to care, cost of care, and satisfaction with care are very important in the design of public insurance. In contrast, profits are of utmost importance in private insurance.

This study confirms that the private insurers will sacrifice access, cost, and satisfaction in order to increase profits. Patients have much higher access to care, financial protection, and satisfaction with public insurance. Shouldn’t we be demanding single payer Medicare for All so that we can all have what we want in health care, and so that we can free up the private insurers to engage in productive occupations that would be a greater benefit to society?

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Time to Abandon Pay For Performance

Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study, JAMA Health Forum, May 14, 2021, By Dhruv Khullar, Amelia M. Bond, Eloise May O’Donnell, Yuting Qian, David N. Gans, and Lawrence P. Casalino

“Participating in the MIPS program results in substantial financial and time costs for physician practices. We found that, on average, it cost practices $12 811 per physician to participate in MIPS in 2019. We found that physicians themselves spent a considerable amount of time to participate in MIPS. In 2019, physicians spent more than 53 hours per year on MIPS-related activities, which translates to nearly $7000 per physician. If physicians see an average of 4 patients per hour, then these 53 hours could be used to provide care for an additional 212 patients a year—equal to more than a full week’s work for a physician.”

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Comment by Adam Gaffney

Pay-for-performance (P4P) is an increasingly central part of the American healthcare landscape. The Affordable Care Act added a multitude of new P4P programs to Medicare, including the Hospital Readmissions Reductions Program (HRRP) and the Hospital Value-Based Purchasing Program (HVBP). Then, the Medicare Access and CHIP Reauthorization of 2015 gave us the Merit-based Incentive Payment System (MIPS), a new P4P program that imposes financial sticks and carrots on individual clinicians across the country based on a slew of complicated performance metrics.

Much research suggests that these programs have little effect on patient outcomes. The HRRP was much lauded for apparently reducing readmissions, but later research attributed much (or all) of this apparent reduction to changes in diagnostic coding. There is also some evidence HRRP may have harmed some cardiac patients. Meanwhile, studies of the HVBP have found virtually no impact. Fewer studies, however, have examined the costs of such programs.

That’s what makes this study, led by Dr. Dhruv Khullar at the Weill Cornell Medical College, so valuable. The researchers interviewed the leaders of 30 physician practices across the nation who participated in the MIPS, and quantified the costs of participation in the program. Overall, they found that we spend more than $12,000 per physician annually to cover the administrative costs of participation in MIPS. Additionally, “MIPS-related activities” suck up over 200 hours of labor per year from practice staff, including 53.6 hours from frontline clinicians. And this is merely for a single P4P program.

There is little evidence, in other words, that P4P programs substantively improve care — and growing evidence that they further inflate our already enormous administrative costs while sapping the time and energy of practicing doctors. For these reasons, P4P should not be included in a Medicare for All reform. Notably, the House Medicare for All Bill excludes this payment mechanism. The underlying political idea of P4P is a fundamentally neoliberal one: the idea that we are all motivated only by pursuit of the dollar. Instead, doctors want to provide the best care they can. That it is not to say that there isn’t room for quality improvement in our healthcare system — far from it — but a paucity of profit incentives is not the culprit. Further, an increasing number of studies show that P4P is redistributive — shifting funds from providers that care for poorer patients (who tend to have worse outcomes) to the providers of the wealthy.

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Single Payer Must Include Rational & Compassionate Long Term Care

Health Care Use and Out-of-pocket Spending by Persons With Dementia Differ Between Europe and the United States, Medicare Care, June 2021, By Sabrina Lenzen, Pieter Bakx, Judith Bom, Eddy van Doorslaer

Background: Persons with dementia need much care, but what care is used and how the burden of financing is divided between persons with dementia, caregivers, and public programs may differ between countries.

Objective: The objective of this study was to compare how health care use and out-of-pocket (OOP) spending associated with dementia differ between the United States and Europe, with and without controlling for background characteristics.

Research Design: We use prospectively collected survey data from the United States-based Health and Retirement Study (n=48,877) and the Survey of Health, Ageing, and Retirement in Europe (n=98,971) including all adults over the age of 70 years. Dementia status is imputed using a validated algorithm…

Results: Persons with dementia in the United States use 50% less formal home care per year than persons living with dementia in Europe [mean (SD)=236.8 h (1047.4) vs. 463.3 h (1371.2)], but use more nursing home care [75.1 d (131.4) vs. 45.5 d (119.4)). Dementia is associated with higher OOP spending in the United States than Europe [$4406 (95% confidence interval, 3914-4899) vs. $246 (73-418).

Conclusions: The far greater reliance on nursing home care in the United States likely causes much higher expenditures for people with dementia and insurance programs alike.

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Comment by Steffie Woolhandler and David Himmelstein

When individuals require extensive assistance with daily living, most patients and families prefer home care to care in a nursing home. The COVID-19 pandemic has highlighted the sorry state of long term care – particularly nursing home care – in the US. This study documents the far greater reliance in the US as compared to Europe on nursing homes (67% more nursing home days per year on average) for the care of dementia patients, a corollary of the US deficit for home care (49% fewer hours). And the out-of-pocket costs to patients are also strikingly different: more than $4000 higher per patient in the US in 2017.

Single payer reform must include a rational and compassionate long term care program. Although not detailed in this article, the programs in several European nations include key elements that should be adopted in the US – e.g. salaries for family members who forego other paid employment to care for a disabled loved one, and the provisions of full time (or respite) live-in caretakers.

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ACA Marketplace 2021 Enrollment Rise in Nonexpansion States – No Cure

UI effect? ACA marketplace enrollment soared at low incomes in nonexpansion states in 2021, XPOSTFACTOID, May 3, 2021, By Andrew Sprung

I don’t think it’s an exaggeration to say that enrollment [in ACA marketplace plans] at the lowest subsidy-eligible income levels in nonexpansion states exploded this year. 

Enrollment at 100-150% FPL in these fourteen states increased by 16.7% over 2020. For comparison, total marketplace enrollment in all states at all income levels was up 5.2% this year. The total increase in this income bracket in these fourteen states, 424,957, is 71% of the entire increase nationwide, 594,918. 

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Comment by Isabel Ostrer

Over one million Americans have newly enrolled in Affordable Care Act marketplace plans this year. This was facilitated by President Biden expanding the enrollment period as a response to Covid-19 pandemic-caused mass unemployment and ongoing health fears for many Americans. Many millions remain uninsured.

Indeed, the pandemic has exposed the rickety scaffolding on which U.S. health insurance is constructed. Over half of Americans receive insurance through their jobs. But the rest of adults under age 65 — working or not — face a conundrum. They must either be poor enough to qualify for Medicaid (a near impossibility in certain states — like Texas, where an adult must earn <14% of the federal poverty line (FPL) to qualify for Medicaid) or earn enough to qualify for subsidized coverage through the ACA marketplace (in nonexpansion states subsidies start at 100% FPL). 

What happens to Americans who fall through the scaffolding? There is huge pent-up demand for health insurance in this group. With recently increased unemployment income (also pandemic-era legislation), many adults in nonexpansion states have been nudged into an income tier where they qualify for subsidized marketplace plans. As health policy expert Sprung points out in his post, every nonexpansion state except Wisconsin has seen a surge in enrollment among adults who earn 100-150% FPL. 

Despite these coverage gains, tens of millions of Americans remain ineligible for health insurance. Instead of propping up our piecemeal insurance system and padding the pockets of private corporations in the process, the obvious solution is a shift to unified single payer insurance. All Americans deserve access to affordable, comprehensive health insurance. Single payer is the answer.

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COVID Payment Burdens Echo How U.S. Health System Routinely Fails Patients

Covid Killed His Father. Then Came $1 Million in Medical Bills., NY Times, May 21, 2021, By Sarah Kliff

Insurers and Congress wrote rules to protect coronavirus patients, but the bills came anyway, leaving some mired in debt.

“People think there is some relief program for medical bills for coronavirus patients,” said Jennifer Miller, a psychologist near Milwaukee who is working with a lawyer to challenge thousands in outstanding debt from two emergency room visits last year. “It just doesn’t exist.”

Many large health plans wrote special rules, waiving copayments and deductibles for coronavirus hospitalizations. When doctors and hospitals accepted bailout funds, Congress barred them from “balance-billing” patients — the practice of seeking additional payment beyond what the insurer has paid.

Interviews with more than a dozen patients suggest those efforts have fallen short. Some with private insurance are bearing the costs of their coronavirus treatments, and the bills can stretch into the tens of thousands of dollars…

Some hospitals are not complying with the ban on balance billing. Some are incorrectly coding visits, meaning the special coronavirus protections that insurers put in place are not applied. Others are going after debts of patients who died from the virus, pursuing estates that would otherwise go to family members…

Coronavirus patients face significant direct costs: the money pulled out of savings and retirement accounts to pay doctors and hospitals. Many are also struggling with indirect costs, like the hours spent calling providers and insurers to sort out what is actually owed, and the mental strain of worrying about how to pay.

Ms. Miller, like many other patients, described trying to sort out her complicated medical charges — in her case in color-coded folders — while also battling the mental “brain fog” that affects as many as half of coronavirus long-haul patients.

“I have a Ph.D., but this is beyond my abilities,” she said. “I haven’t even begun to look at my 2021 bills because we’re still dealing with 2020 bills. When the bills come nonstop, you can only deal with so much.”

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Comment by Jim Kahn

COVID care was supposed to be the exception: amidst a pandemic, insurers agreed to cover all medical care related to this infection, with no cost-sharing for patients. But it didn’t happen. These interviews in the New York Times show how patients and their surviving family members were saddled with tens of thousands of dollars in cost-sharing, and many hundreds of hours at the kitchen table and on the phone trying to sort out the deluge of bills, long after their loved one was gone.

What went wrong? The short answer is that our system is so inherently complex and dysfunctional that it couldn’t pull itself together, even in an emergency.

Here are the sordid details: 

Our system relies extensively on cost-sharing (deductibles, copays). That means that forgiving the cost-sharing burden is an issue – not so in other wealthy countries. 

Second, it’s complicated to manage these complex financial rules, leading to huge administrative burdens for insurers, providers, and… patients and families.

Third, the insurers “agreed” to cover all COVID care. No force of law.

Fourth, a catch: the offer to forego cost-sharing depends on a diagnostic code for COVID. What if somebody has multiple medical problems – as is true for many of the sickest with COVID? If the COVID code isn’t prominently noted, that person loses out.

And, finally, preoccupation with profit. Another recent New York Times story describes how hospital chains used federal COVID relief funds to grow their clinical empires and thus profits. Shareholders win, people lose.

When will we learn? We must commit to universal, equitable high quality care – healthcare justice – combined with the efficiency of simplicity. What’s that called? Single payer.

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Time to Take to the Streets to Demand Medicare for All!

Sanders, Jayapal Put Single Payer Medicare for All on Back Burner, Corporate Crime Reporter, May 10, 2021, By Russell Mokhiber

Single payer activists want Medicare for All front and center in Congress.

But Senator Bernie Sanders and Congresswoman Pramila Jayapal have put the issue on the back burner.

Sanders has yet to reintroduce his single payer legislation in the Senate. 

Instead, Sanders is pushing for a step by step approach – dropping the Medicare age to 60 and expanding it to cover dental, hearing and vision.

This step by step approach is justified by Sanders supporters like Michael Lighty who wrote recently that “Medicare for All isn’t yet winnable – expansion is.” 

And while Congresswoman Jayapal introduced her Medicare for All legislation (HR 1384) in March, she made it clear that she was more interested in the Sanders step by step approach.

Inside the beltway progressives refuse to challenge Sanders and Jayapal.

But Kay Tillow of The All Unions for Single Payer Health Care in Louisville, Kentucky says that the step by step approach won’t work.

And she questions why Sanders and Jayapal didn’t just re-introduce HR 676, the original single payer proposal in the House.

Tillow wrote to Jayapal at the end of December 2020 with her concerns…

“We are deeply concerned that HR 1384, the bill that succeeded Congressman John Conyers’ HR 676, dropped some of the key principles that were in Conyers’ model single payer bill,” Tillow wrote to Jayapal. 

“There is no reason for any compromises to be made at this point. We need model legislation that sets the stage for the struggle that is to come. If a principle is not placed on the table at the beginning of the bargaining, it is conceded. Unionists know that the outcome does not improve in the negotiations. The effort for the integrity of the single payer model in actual legislative form needs to be made.”

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Comment by Don McCanne

Bernie Sanders, Pramila Jayapal, and Michael Lighty – heroes of the single payer Medicare for All movement – are also political pragmatists. But Kay Tillow is a political realist. “If a principle is not placed on the table at the beginning of the bargaining, it is conceded. Unionists know that the outcome does not improve in the negotiations.”

Recent media reports have indicated that our heroes recognize the political barriers to reform and are now posturing with the view that we should support beneficial measures that may not get us all the way there. Perhaps the most prominent isolated policy that is gaining support is lowering the eligibility age for Medicare – a view that some think that President Biden may eventually agree to as a compromise.

Where are the insurers and the medical-industrial complex on this? Of course, they are opposed. But are they really? Almost half of Medicare has already moved into the private insurance Medicare Advantage plans. Since some believe that Medicare for All is inevitable, what better strategy could they have than to complete the conversion to private Medicare Advantage for All? That concept is sneaking into the health policy literature, and it certainly wasn’t us who put it there.

Oh, you say, that won’t happen because we will be able to follow up with the Medicare public option. But isn’t that just another insurance plan that will be plugged into the Medicare Advantage insurance exchange?

Never fear. We are being told that President Biden has proven to be a great progressive like Franklin Delano Roosevelt. But wasn’t it FDR who threw health insurance out of the Social Security Act?

Kay Tillow has warned us that we can’t take anything off of the table, but we already have, and we are poised to take much more off.

Instead, we should be taking to the streets screaming for health care justice for all. Listen… silence. We have to change that. Now!

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Guarantee Coverage for All Medically Necessary Services – Including Reproductive Care

Supreme Court to review Mississippi abortion law that advocates see as a path to diminish Roe v. Wade, Washington Post, May 17, 2021, By Robert Barnes

“The Supreme Court announced Monday that it will review a restrictive Mississippi law that provides a clear path to diminish Roe v. Wade’s guarantee of a woman’s right to choose an abortion.

Abortion opponents for months have urged the court’s conservatives to seize the chance to reexamine the 1973 precedent. Mississippi is among many Republican-led states that have passed restrictions that conflict with the court’s precedents protecting abortion rights, hoping for a chance to get a case before a Supreme Court that they think is more amenable to their arguments.

In accepting the case for next term, the court said it would examine whether “all pre-viability prohibitions on elective abortions are unconstitutional.” That has been a key component of the court’s jurisprudence, and the announcement sounded ominous to abortion rights advocates.”

The incomplete promise of Medicaid expansion, Vox, May 17, 2021, By Dylan Scott 

“In November, Missourians voted to expand Medicaid under the Affordable Care Act, granting access to health insurance to roughly 230,000 people living in poverty. Now the state’s Republican legislators are defying the will of their voters by refusing to implement the expansion.

In late April, the Missouri Senate blocked funding for Medicaid expansion. Last week, Gov. Mike Parsons cited the lack of funding to justify withdrawing the expansion plan entirely.

The pattern demonstrates that, nearly a decade after the Supreme Court ruled that states could choose whether to expand their Medicaid programs, the fight over whether to do so is far from over. So far, 38 states and Washington, DC, have expanded Medicaid, covering nearly 15 million people. In the dozen states that have not, 4 million people are uninsured who would receive Medicaid coverage if their state expanded eligibility under the ACA. More than 95 percent live in the South, they are disproportionately Black, and many are not eligible for subsidies to buy private coverage on the ACA markets.”

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Comment by Eagan Kemp

While these two stories may not initially seem linked, Medicare for All supporters know that they both highlight just how tenuous access to health care remains when subject to the whims of states. Numerous states continue to fail their residents by refusing to expand Medicaid and also by attempting to restrict access to reproductive services, especially abortions. 

The answer to both of these problems is Medicare for All, which would guarantee coverage for all medically necessary services, including abortion and the full spectrum of reproductive health care services, and ensure that everyone in the U.S. can finally get the health care they need, regardless of where they live. 

Failure to pass Medicare for All and end the Hyde Amendment that sharply limits federal funding for abortion means that states can restrict health care access. If the Supreme Court overturns or severely curtails the protections provided by Roe v. Wade, many states would pass even more restrictive provisions inhibiting the right to choose. Many of the same states continue to refuse to expand Medicaid, even when approved in a referendum by a majority of state voters, as is in Missouri. 

This situation will place many pregnant women in a catch-22: both unable to afford the massive medical bills that come with pregnancy because they cannot access Medicaid (which pays for >40% of pregnancies nationwide), and unable to seek a legal abortion.

The time has come to protect reproductive rights from reactionary state forces, reverse the Hyde Amendment, and finally ensure that everyone in the U.S. can get the care they need when required. It’s time for Medicare for All.

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Hospital and Group Practice Profit Motive Poses as Big a Threat as Insurers

Recent Changes in Physician Practice Arrangements: Private Practice Dropped to Less Than 50 Percent of Physicians in 2020, AMA Economic and Health Policy Research, May 2021, By Carol K. Kane

“2020 was the first year in which less than half (49.1 percent) of patient care physicians worked in a private practice—a practice that was wholly owned by physicians. This marks a drop of almost 5 percentage points from 2018, when 54.0 percent of physicians worked in physician-owned practices, and a drop of 11 percentage points since 2012. In 2020, almost 40 percent of physicians worked directly for a hospital or for a practice at least partially owned by a hospital or health system.

The shift toward larger practice size, which has been ongoing for many years, also appears to have accelerated between 2018 and 2020. The percentage of physicians in practices with at least 50 physicians increased from 14.7 percent in 2018 to 17.2 percent in 2020.

Fifty percent of physicians were employed, 44.0 percent had an ownership stake in their practice, and 5.8 percent were independent contractors in 2020. The employee percentage was up from 47.4 percent in 2018 and 41.8 percent in 2012.”

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Comment by Steffie Woolhandler and David Himmelstein

The rapid shift from private practice to employment by large corporate organizations – a shift that’s even more marked among doctors under 40, 70% of whom were employees by 2020 – has important implications for health care reform. Insurers’ profit-seeking is the main threat to the clinical independence of doctors in private practice. But pressure from employers seeking to bolster their bottom line is an additional threat – sometimes the main one – for those whose paycheck comes from a hospital, health system, group practice or private equity firm. Private practitioners lose income if they offer free care to an uninsured patient, open their practice to Medicaid patients who bring scant reimbursement, or advise patients to hold off on undergoing a lucrative procedure. Employed doctors risk losing their jobs for repeated offenses against their organization’s profitability.

Hence, this latest AMA survey data highlights the importance of eliminating profit incentives that bend clinical priorities in both non-profit and for-profit health care institutions. For-profits should be banned, as Medicare used to do in its home care program. Non-profits should be paid global operating budgets and prohibited from retaining any surpluses or using the money not spent on patients for outrageous executive compensation or profit-based bonuses for employees.

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Learning from COVID-19: Public Funding of Drug Development

The covid-19 vaccine patent waiver: a crucial step towards a “people’s vaccine”, BMJ blog, May 10, 2021, By Gregg Gonsalves and Gavin Yamey

“An IP waiver would allow other producers to step in and make raw materials for export for all the current vaccines, industrial parts, and components. It would also simplify agreements for eventual production of more doses. But an IP waiver alone will not solve the covid-19 vaccine access challenge. Two further steps will need to be taken to reach a people’s vaccine. Step two is a transfer of technical know-how from vaccine makers in the global north to regional hubs or directly to manufacturers in the global south. Step three is vast subsidization of manufacturing in LICs and LMICs. 

Thousands of lives can be saved immediately through a donation model. But at the same time, we need to get going now on a people’s vaccine, since the ramp-up of vaccine manufacturing will take time. Companies in LICs and LMICs are hungry to get going. When the WHO recently announced it was seeking LIC/LMIC manufacturers who want to produce mRNA COVID-19 vaccines, it was inundated with proposals. Right now, the world’s scientists and politicians need to pull together to figure out how to get the next steps done. Technology will need to be transferred to a set of potential new producers, which will require experts to be mobilized for this task, many at the originator companies themselves. New financial resources must be mobilized to support building new factories or retrofitting old ones and to coordinate supply chains and other operational tasks at a global scale. The sooner we start, the faster we bring an end to the pandemic.”

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Comment by Adam Gaffney

Two weeks ago, England saw zero deaths from COVID-19, a testament to the efficacy of vaccines and to the NHS’ efficient vaccination campaign. Similarly, with a majority of its population vaccinated, Israel (but not the neglected Occupied Palestinian Territories) has seen a remarkable retreat of SARS-CoV-2. And the US appears to be following — my state of Massachusetts announced zero COVID deaths on May 10th. Meanwhile, the pandemic is continuing its horrifying course in nations including India and Brazil. Global vaccine apartheid is, in part, to blame for these divergent paths.  

COVID-19 vaccines should have been delivered and distributed, on the basis of need, to every nation on Earth; instead, rich nations (including the US) have signed contracts with pharmaceutical firms allowing them to horde vaccine supplies far in excess of population needs.  

As public health experts Gregg Gonsalves and Gavin Yamey noted in the British Medical Journal, vaccine donations to low-income nations could save lives immediately. However, as they also argue, controlling the pandemic worldwide requires ramping up global production of a “People’s Vaccine” unrestrained by patent protection.  

Intellectual property regimes have long resulted in artificial shortages of needed pharmaceuticals. The COVID-19 pandemic is no exception, but this could have been avoided.  As Physicians for a National Health Program’s 8-point COVID-19 response plan noted more than a year ago,

“…the US should eliminate intellectual property constraints like patents and trade agreements that might restrict the low-cost production and distribution of essential drugs and vaccines, including those developed from publicly-funded research.”

The Biden administration took a step in the right direction last week when it endorsed a waiver of patent rights on COVID-19 vaccines. However, as Gonsalves and Yamey note, this is not enough. While removal of patent protections allows generic drug manufacturers around the globe to cheaply produce small molecule pharmaceutics, the production of more complex biologic agents, including vaccines, additionally requires a transfer of technology, e.g.. the knowhow and trade secrets that go into the production process, as well as financial support. But this is something that we can do — indeed, it should have begun already.

Some have questioned the utility of this approach, or decried “patent busting” more broadly. However, as James Love’s Knowledge Ecology International (KEI) has shown, “companies with pre-existing drug and vaccine manufacturing capabilities can start producing COVID-19 vaccines relatively quickly, if technology transfer is made.” KEI has compiled a database of outsourcing agreements involving technology transfer for COVID-19 vaccine production, and concluded: “In almost all of the cases where information is available the manufacturer said that they were going to make the first delivery, or actually started delivering [vaccines], within six months from the deal announcement date.” 

The lessons to be drawn from this episode should extend beyond the pandemic. A drug development system driven by windfalls from intellectual property ownership is neither just nor efficient — nor is it necessary. We already publicly-fund much of the basic research that underlies drug development; we could publicly-fund the whole pipeline — including clinical trials — as well. As PNHP’s comprehensive pharmaceutical proposal, published in the British Medical Journal in 2018, set forth, we need a path of full public funding of pharmaceutical development by the National Institutes of Health. Such a program would deliver agents that would be in the public domain immediately — for the benefit of the entire global community.