Protests for Gun Safety … & Health Care Justice

Interview of former Gov. John Kasich (R, Ohio) after tragic school shooting in Nashville
MSNBC
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.

Americans Angry about Flawed Health Insurance

Americans Are Angry About Their Health Insurance – With Good Reason
Common Dreams
Jan. 1, 2025
By Claudia Fegan, MD (National Coordinator, PNHP)

As a physician, I have seen patients suffer and die in order to pad the bottom lines of corporate health insurers – and in recent years I have seen this problem getting much worse.

How should we react when a man is shot to death on the street on his way to work? Our humanity tells us that we should be shocked and horrified.

 So why did hundreds of thousands of people have the exact opposite reaction when UnitedHealthcare’s CEO was executed in New York City? Because Americans are furious with health insurance corporations – and they have every right to be.

In the immediate aftermath of the shooting, many Americans took to social media to celebrate. Sympathetic statements were met with rancor – and in the case of UnitedHealth Group’s own statement, over 70,000 “laugh reactions” before the company made that tally private.

As a physician who’s treated countless victims of gun violence, and whose life’s work is to care for all of my patients, I found this response to be deeply unnerving.

For decades, health insurance corporations like United have been taking in as much money as possible in premiums and paying out as little as possible in medical claims. They have tried everything from requiring “prior authorization” of care, to excluding high-quality providers from their networks, to imposing a Byzantine series of charges including ever-growing copays, coinsurance and deductibles. When all else fails, many insurers simply deny claims.

Behind each of these practices are millions of Americans who are made to suffer. I hear these stories routinely in my practice, and they never become easier to stomach. I have seen patients with aggressive cancer who avoided seeing a doctor for months because they feared bankruptcy; patients with chronic conditions like diabetes who are denied treatments that would improve their quality of life; and gunshot victims whose fight to recover and gain a semblance of normalcy is complicated by their health plans saying no, no, and no again.

I have seen patients suffer and die in order to pad the bottom lines of corporate health insurers – and in recent years I have seen this problem getting much worse.

Are we listening? And what are we going to do about it? Both the Affordable Care Act and the Medicare Advantage program have only succeeded in ballooning the profits of firms like United – without improving Americans’ health or sparing their wallets.

What would help is a proven reform proposal that is long overdue: a single-payer national health program. Such a system would provide universal coverage and comprehensive benefits – with zero out-of-pocket costs.

Americans are crying out in pain. We should listen to those cries and we should finally, after decades of delay, do something about it.

 

Comment by: Don McCanne

I started in practice before Medicare and Medicaid were implemented. What a relief it was to see seniors finally able to receive care without facing significant financial barriers to that care. And others living in poverty were also able to receive care since their financial barriers were removed, and Medicaid did cover overhead, allowing dedicated physicians to practice without worrying about negative cash flows.

But there were still too many patients who remained uninsured or whose employer-sponsored plans were shifting more expenses to the patient through higher premiums and cost sharing, while limiting patient choices through managed care manipulations.

With my growing dissatisfaction with our health care system, it was in 1989 that I read an article in JAMA, written by Steffie Woolhandler and David Himmelstein, co-founders of Physicians for a National Health Program, that described a single, tax-funded national health program that they supported. That was it! Precisely what we needed! I immediately became affiliated with their organization. Claudia Fegan became one of my mentors, leading me through the early stages of my involvement. She has been an inspiration to me ever since.

Her article explaining how the defects in our health care financing system only continue to grow certainly resonates with me. We now have the most expensive health care system which performs worse than all other modern nations. We recently estimated in HJM as many as 200,000 deaths each year due to insurance problems like those described by Dr. Fegan. You can see why I am absolutely elated to see her article as she continues to fight for the cause of health care justice for all.

The tragedy of the assassination pains us all, but the enormity of the public reaction to the injustice that the private insurers inflict upon the American people suggests that there is hope that we will finally fix the system. If our legislators and administration do not respond to the current protests, it means that we need to raise our voices even louder (while refraining from assassinations and Jan. 6-type events, since, in our mission, we revere life).

Shareholder Dreams or Health Justice?

Health Insurers Gave $120 Billion To Shareholders While Denying Your Claim
The Lever
Dec. 11, 2024
By Veronica Riccobene

As rising health care costs and inadequate insurance coverage have one in three Americans saddled with medical debt, the nation’s top health insurers have dumped billions into enriching their executives and top shareholders through lucrative stock buybacks.

All in all, the country’s largest health insurers have invested over $120 billion into repurchasing their own shares since the passage of the Affordable Care Act in 2010. These include UnitedHealth Group; Cigna; Elevance Health, the parent company of Anthem Blue Cross Blue Shield; and CVS Health, which acquired Aetna in 2018.

These companies, along with Kaiser Permanente, a nonprofit health care organization, control over half of the commercial market share of the U. S. Health insurance industry. Since 2010, they’ve raked in a combined $9 trillion in revenue, netting more than $371 billion in profits.

Meanwhile, one in four Americans say they’ve avoided seeking health care in the past year because of the cost. Half of all U.S. adults say they’d be unable to afford an unexpected $500 medical expense, and medical bills account for 40 percent of U.S. bankruptcies.

Major insurers have abandoned patients for shareholder enrichment, according to former health insurance executive Wendell Potter. “Health insurers corrupted the concept of managed care and turned it into something that has really been more of managing cost, but also depriving people of the care that they need,” said Potter. “There’s no other country in the world that has a system like this that enables middlemen to siphon off so much money from middle-class and working-class folks that need health care,“ he added.

Nearly two in three Americans now say they believe health care should be the government’s responsibility, according to polling organization Gallup.

Data shows buybacks soared after Congressional Republicans and the Trump administration slashed corporations’ tax burden through the Tax Cuts and Jobs Act of 2017. Proponents of the Trump tax cuts argued that corporations would reinvest their savings into research and workers – but instead, buybacks exploded. Corporate buybacks are on track to surpass $1 trillion annually by 2025.

 

Comment by: Don McCanne

Remember, this is only one game that corporations play to move our health care dollars to their own profit line. Their combined maneuvers to reduce health spending on us as they boost their own profits is what has made the health care system in the United States the most expensive and poorest-performing system of wealthy nations.

This is certainly not news to those of us who have now worked decades to try to bring us the model of health care reform that would enable everyone to have access to comprehensive health care without increasing the total health care spending in the U.S., and that model is a single payer system that would be similar to an improved version of Medicare that covered everyone. Many studies have now shown us that this is precisely the reform that we need to provide health care for everyone without creating any personal financial hardship.

The problem is that we still have too many politicians and members of the media that respond in a rote manner with phrases such as, “We can’t afford that” (we can), or “The people don’t want the government involved” (countered by numerous surveys), or “But that’s socialized medicine” (not a bad concept when it is applied to our traditional Medicare as well), or etc., etc.

The solution is that we can no longer accept any of these phrases that tend to reject the concept when we know that single payer is exactly what we need. Now, in such instances, we need to be emphatically but politely curt as we immediately reject the negative comment whenever it is brought up and replace it with politely stern corrections, with special attention to the true facts (“politely stern”: are we creating a new, more appropriate communication standard?).

Anyway, no more passive dismissals. We need to enact and implement a system that works well for all of us, and we need to do it now. We must bring an end to the decades of delay: Health Care Justice for All – NOW and FOREVER!

PEACE AND CHARITY BE WITH US.

Estimated US Deaths Associated with Health Insurance / Access to Care

This week, a careful reader asked me to justify this estimate from November 2021: “The US excess mortality age 20-64 is about 1.4 per 1000 per year. Some of that is due to non-insurance factors. If 1.0 per 1000 is attributable to insurance, applied to the 190 million in this age range, that’s 190,000 extra deaths per year.”

In 2021, I was making a rough estimate by assigning most of the inter-country difference among adults 20-64 to health insurance. Perhaps I didn’t sufficiently emphasize the uncertainty of that estimate. Today, to “triangulate”, I took a different approach. I looked up death rates for major risk factors and diagnoses more common in the US than in other wealthy nations. This is not yet sufficiently refined for academic publication, but it’s a solid first cut, so I’m sharing it with HJM readers.

This finding of 195,032 annual deaths not explained by risk factors and diseases more common in the US is close to my prior estimate of 190,000. As noted, several of the totals may actually have medical insurance as a contributing cause – e.g., medical debt forcing people into poverty, or suicides associated with insurance worries or lack of access to mental health care. Thus, the 195,032 is likely a low estimate of insurance-related deaths.

To me, this high mortality burden is consistent with our fragmented and flawed insurance system, with half of adults experiencing financial barriers to care in any given year, often with reported health consequences. Growing rates of care denials are likely increasing the human toll, based on both reports of personal experiences and national surveys of physicians.

These kinds of estimates are imprecise, and indeed the uncertainty bounds are hard to specify. However, they are meaningful despite uncertainty. Whether the excess deaths due to insurance gaps total 195,000 per year, or 220,000, or 170,000, that’s hundreds of thousands too many deaths. The 45,000 estimated in 2009 for those lacking insurance altogether (ignoring under-insurance) is also too much, inexcusable.

We need universal public insurance providing broad benefits to everyone, to save lives and money.

 

Sources:

Bor J et al. PNAS Nexus 2023 Missing Americans: “Early death in the United States 1933–2021’

Dehry SE et al. Population Research and Policy Review 2023 “Excess Deaths in the United States Compared to 18 Other High‑Income Countries”

Ward ZJ et al. 2022. EClinicalMedicine “Excess mortality associated with elevated body weight in the USA by state and demographic subgroup”

Peterson-KFF Health System Tracker. 2021 “Country Comparison: Prevalence of obesity”

Commonwealth Fund. 2024 “Comparing Deaths from Gun Violence in the U.S. to Other Countries”.

Morbidity and Mortality Weekly Report. 2022 “Motor Vehicle Crash Deaths — United States and 28 Other High-Income Countries, 2015 and 2019”

Roser M. Our World in Data 2020 “Why is life expectancy in the US lower than in other rich countries?”

The Flawed Corporate Health Care Model

UnitedHealth Group C.E.O.: The Health Care System Is Flawed. Let’s Fix It.
New York Times
Dec. 13, 2024
By Andrew Witty, C.E.O. UnitedHealth Group, parent company of UnitedHealthcare

As Brian Thompson’s family, friends and colleagues mourn his killing, we are bearing a grief and sadness we will carry for the rest of our lives. We greatly appreciate the enormous outpouring of support for Brian, who ran our health insurance business, UnitedHealthcare, as well as for our wider company, which I lead. Yet we also are struggling to make sense of this unconscionable act and the vitriol that has been directed at our colleagues who have been barraged by threats. 

We know the health system does not work as well as it should, and we understand people’s frustrations with it. No one would design a system like the one we have. And no one did. It’s a patchwork built over decades. Our mission is to help make it work better. We are willing to partner with anyone, as we always have — health care providers, employers, patients, pharmaceutical companies, governments and others — to find ways to deliver high-quality care and lower costs. 

Clearly, we are not there yet. We understand and share the desire to build a health care system that works better for everyone. That is the purpose of our organization. 

Brian was never content with the status quo. That’s why he pushed us to build dedicated teams to help the sickest people navigate the health system. It’s why he fought for preventive health and quality health outcomes rather than simply adding ever more tests and procedures. He believed decisions about health care should start with the individual and championed plans in which consumers could see costs and coverage options upfront, so they could decide what’s best for themselves and their families.

The ideas he advocated were aimed at making health care more affordable, more transparent, more intuitive, more compassionate — and more human.

That’s Brian’s legacy, one that we will carry forward by continuing our work to make the health system work better for everyone.

Optum: The $101 Billion Division of United Health Group Explained
YouTube video (3 min)
AHealthcareZ – Healthcare Finance Explained
Nov. 30, 2020
With Dr. Eric Bricker

Optum is almost half of UnitedHealth Group’s business. The other half is UnitedHealthcare, which is the insurance company. Not only is Optum about half of their revenues, it’s about half of their earnings.

What does Optum own? It’s kind of made up of a whole bunch of things (Advisory Board Co., Optum Analytics, Optum Bank, OptumRx – a PBM, etc.)

The point of this talk is that Optum is supposed to be advocating for companies and their employees while, at the same time, Optum is getting paid by hospitals to increase their revenue. I’m not quite sure what to make of this, but it’s a big deal, and I just want to bring that to your attention.

United Health Group’s 5 Highest Earning Executives in 2023
Becker’s Payer Issues
April 22, 2024
By Rylee Wilson

UnitedHealth Group CEO Andrew Witty was paid $23.5 million in total compensation in 2023. Mr. Witty’s total compensation increased $2.6 million from 2022, according to documents the company filed with the SEC April 22.

 

Comment by: Don McCanne

We’ve been saturated and saddened by comments about the tragic killing of UnitedHealthcare’s CEO, but perhaps we are even more astounded by the intensity of the public’s response against the insurance company that Brian Thompson represented. So it seems like it would help us understand the situation better by reading the response of Andrew Witty, the CEO of UnitedHealthcare’s parent company, UnitedHealth Group.

In an attempt to assuage the sorrow and anger of the public at large, Witty explains that no one would design a health care system like the one we have now, but that their mission is “to help make it work better.“ Andrew Witty says that they will carry forward Brian Thompson’s legacy of “making health care more affordable, more transparent, more intuitive, more compassionate — and more human.”

But let’s look at their business model. Half of the company is about health insurance, and we all know about the dysfunctional changes that have taken place in the health insurance we have ended up with — massive profits, narrow & flawed provider networks, prohibitive deductibles and cost-sharing, and rising prior authorization denials. Ours is the most expensive health care system, yet it significantly underperforms compared to other wealthy nations. Far too many are left underinsured or even uninsured. This is a legacy of making health care more affordable, more compassionate, and more human? Don’t think so.

It hardly seems that their mission is, as they claim, about improving health care for all. About half of their business model is in Optum. Optum isn’t about the rendering of health care; it’s about the business of health care. It’s about taking our health care dollars and moving them into their business model. It’s about money! It’s about profits!

Andrew Witty wants us to be impressed by the humane nature of their model, even if it has not performed as well as we think it should. In fact, their hidden mission of wealth creation for their executives and investors might be better exemplified by his compensation increase of $2.6 million in the latest year for which we have a breakdown of his $23.5 million compensation. That’s quite a reward for someone who is supervising the degradation of our health care financing system.

In my opinion, Mr. Witty’s attempt to calm us down has failed. More than ever, for the health of our nation, we see that it is imperative that we eliminate this industry and replace it with a single payer system, a carefully improved version of Medicare that serves all of us while making it equitable, comprehensive, accessible, and affordable.

But, please, no tragedies. Let’s make the system function effectively for everyone. We can do this together.

(Although Mr. Witty might be expected to attend the health care negotiations, he should surely understand when we politely ask him to take a seat in the back row.)

Deaths due to Willful Systemic Failings are Violent, Too

A Man Was Murdered in Cold Blood and You’re Laughing?
What the death of a health-insurance C.E.O. means to America.
The New Yorker
December 7, 2024
By Jia Tolentino

The C.E.O. of UnitedHealthcare, fifty-year-old Brian Thompson, was murdered on the street in midtown Manhattan …

The public reaction has been wild, lawless. The jokes came streaming in on every social-media platform, in the comments underneath every news article. “I’m sorry, prior authorization is required for thoughts and prayers,” someone commented on TikTok, a response that got more than fifteen thousand likes. “Does he have a history of shootings? Denied coverage,” another person wrote, under an Instagram post from CNN. On X, someone posted, with the caption “My official response to the UHC CEO’s murder,” an infographic comparing wealth distribution in late eighteenth-century France to wealth distribution in present-day America. The whiff of populist anarchy in the air is salty, unprecedented, and notably across the aisle. New York Post comment sections are full of critiques of capitalism as well as self-enriching executives and politicians (like “Biden and his crime family”). On LinkedIn, where users post with their real names and employment histories, UnitedHealth Group had to turn off comments on its post about Thompson’s death—thousands of people were liking and hearting it, with a few even giving it the “clapping” reaction. The company also turned off comments on Facebook, where, as of midday Thursday, a post about Thompson had received more than thirty-six thousand “laugh” reactions.  … 

The Norwegian sociologist Johan Galtung coined the term “structural violence” in 1969, in a paper that offers a taxonomy of violence—ways to distinguish between the forms that violence can take. … It can be manifest, or latent. Traditionally, our society fixates on only one version of this: direct physical violence committed by a person intending harm. … 

On this point, though, everyone’s really in agreement. It’s just a matter of where you locate the decay—in the killing, or in the response to it, or in what led us here. The only way to end up in a situation where a C.E.O. of a health-insurance company is reflexively viewed as a dictatorial purveyor of suffering is through a history of socially sanctioned death. … Nurses, residents, aides, specialists—they are asked to absorb the rage and panic induced by the American health-care system, whose private insurers generate billions of dollars in profit and pay executives eight figures not despite but because of the fact that they routinely deny care to desperate people in need. 

Of course, the solution, in the end, can’t be indifference—not indifference to the death of the C.E.O., and not the celebration of it, either. But who’s going to drop their indifference first? At this point, it’s not going to be the people, who have a lifetime of evidence that health-insurance C.E.O.s do not care about their well-being. Can the C.E.O. class drop its indifference to the suffering and death of ordinary people? Is it possible to do so while achieving record quarterly profits for your stakeholders, in perpetuity?

 

I Am Torn: Grappling With the Killing of UnitedHealthcare’s CEO
MedPageToday
December 10, 2024
by James Young, MD 

On the one hand, I shed no tears for Thompson. The man made millions off the suffering of others. More than $10 million last year, in fact. Likewise, every penny of the $22 billion in profit made by parent company UnitedHealth Group in 2023 was at the expense of the suffering of others.

I have no small amount of schadenfreude for what has happened to him. Sometimes, I even find myself wanting to crack jokes at his expense. Is Hell going to require a 2-night qualifying stay prior to admission? Does he have a skilled demonic need that would merit admission to Hell? Others have had similar reactions, posting online comments like, “Unfortunately my condolences are out-of-network,” and “Prior authorization is needed for thoughts and prayers.” …

I hate everything that Thompson stood for. I hate everything that his company stands for and will likely continue to stand for. I expect that the UnitedHealth Group PR and legal teams will use his death as an excuse to stifle any substantive debate or legitimate criticism about UnitedHealthcare with the mantra of, “We need to cool the temperature of the conversation,” or some similar, hollow PR statement.

And yet, I find myself troubled by jumping on the bandwagon of hate.

We need to take this opportunity to mourn the loss of another human being, taken by violence on our streets. We need to show compassion to his family.

We need to say with a single voice that we condemn the actions of Thompson and UnitedHealthcare as vehemently as we condemn the actions of his assassin. We need to warn that too many people — both patients and executives — will continue to suffer until insurance giants put the needs of the patient above those of the shareholder. While I don’t condone more killing or violence against health insurance executives, it’s not unlikely. In fact, it’s already happening. But it needs to be made clear that it’s not rhetoric or debate about insurance company malfeasance driving this action, but the companies’ own actions.

We as physicians need to be vocal, engaged, and seize this moment where the public is now engaged and the media watching, to make the case for why insurance in America is broken.

Ben Shapiro Fans TURN ON HIM Over United Health CEO Take
The Kyle Kulinski Show (on YouTube)
Dec 9, 2024

“It’s not left or right. It’s not black or white. It’s rich vs. poor.”

“Remember folks, Ben … knows exactly what he’s doing. He has more in common with the CEO than 99% of us. Radical change is not about the ‘left’ or ‘right”

 

Comment by: Jim Kahn

In my line of work – quantifying the health effects of health policies and programs – every death counts similarly. Death by illness, medical neglect, accident, or murder is … a death. So I bristle when people tell me that a specific death is particularly egregious. True – untimely, unexpected, avoidable deaths carry a particular emotional weight. And age at death can matter in our calculations. But, ultimately, our standard metrics mean that 100 deaths are, roughly, 100 times as bad as one death.

Thus, I resonated with the widespread response to an insurance CEO’s death. Yes it was a tragedy. It seems like he was a nice man, not deserving of this fate.

However, the job he did – CEO of the largest private insurance group in the United States – made him a symbol of what is wrong with our health insurance.

Indeed, our entire broken insurance approach, built on a foundation of private insurance, generates massive clinical harm. Annual deaths due to lack of insurance are estimated at 40,000 – 80,000. COVID deaths linked to uninsurance topped 300,000. Annual deaths attributable to under-insurance are substantial but much harder to estimate: about half of all adults skip or delay care. My own calculation in HJM based on international data estimates >190,000 excess deaths attributable to our fragmented insurance.

We know this, yet we don’t fix it. Why not? Opposition from corporations and the elected officials they support and lobby. That’s systemic violence.

One caveat: As suggested in the various comments and commentaries, what UHC does wrong is care denials. Certainly, those denials are painful, and symbolic of a lack of caring. Yet they are often clinically inconsequential. Much of what we do in medicine (perhaps 20%) is not effective or even harmful, according to the National Academy of Medicine. We are desperate to try every possible intervention to stave off death. Thus, most care denials probably generate little clinical harm. As reviewed above, the real problem is massive gaps in coverage and access.

How can we fix this? Abandon our for-profit corporate approach to health insurance. In favor of a single, not-for-profit public payer, covering everyone with excellent benefits. As many other wealthy nations demonstrate, this saves resources and prolongs life. Let’s protect individuals (CEOs and others), but most of all let’s protect our population.

US Seniors Experience Worst Cost Barriers to Care

Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries
Commonwealth Fund
By Munira Z. Gunja et al.
December 4, 202

Like several other countries, nearly all adults age 65 and older in the U.S. have health coverage. But high out-of-pocket costs in the Medicare program may still make it more difficult for older Americans to receive affordable care compared to older adults in other countries.

 

Comment by: Jim Kahn

I just spent 3 days in Amsterdam, the Netherlands. Everyone seemed quite content. No wonder, given the extremely low prevalence of medical care cost barriers observed in this survey. Similar for most other nations included. The U.S. performs worst overall, by far, and worst or 2^nd worst on each measure. I’m beginning to think that uncertainty in the US on medical care affordability is a major underlying cause of stress, anxiety, and the drive for political upheaval (more on that in a future post).

Now I’m in Nairobi, Kenya, at a meeting about addressing dementia in low-income countries. These nations face huge challenges not only for treatment and care, but also for prevention programming. Because … they have very little money. We in the high-income nations need to do a lot more to help them, and they should more emphatically prioritize heath in their budgets.

The U.S. doesn’t have the excuse of being poor. We have plenty of money – the most in the world. Our problem is that we build our massive health care system (fully 40% of global health spending) to benefit for-profit intermediaries and providers. This drives up costs. And insurance coverage is designed on the flawed premise of “skin-in-the-game” (empirically, it does not control costs). Lots of pain, no real gain.

Best practices, learning from successful approaches, following the leaders … whatever phrase you prefer, it’s long past due for the US to adopt proven practices from peer nations – to assure access while controlling costs.

Choice Among Private Insurance Options Isn’t Real Choice

The State of Health Insurance Coverage in the U.S.

Findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey
November 21, 2024
By Sara R. Collins & Avni Gupta

Survey Highlights

More than half (56%) of U.S. working age adults were insured all year with coverage adequate to ensure affordable access to care.  But there are soft spots requiring policy attention: 9 percent of adults were uninsured, 12 percent had a gap in coverage over the past year, and 23 percent were underinsured, meaning they had coverage for a full year that didn’t provide them with affordable access to health care.

Among adults who were insured all year but underinsured, 66 percent had coverage through an employer, 16 percent were enrolled in Medicaid or Medicare, and 14 percent had a plan purchased in the marketplaces or the individual market.

Nearly three of five (57%) underinsured adults said they avoided getting needed health care because of its cost. 44 percent said they had medical or dental debt they were paying off over time.

Delaying health care has health consequences: two of five (41%) working-age adults who reported a cost-related delay in their care said a health problem had worsened because of it.

Nearly half of adults (48%) with medical debt are paying off $2000 or more; half of those with debt said it stemmed from a hospital stay.

 

Comment by: Don McCanne

When we discuss the problems with financing our health care system, many in the policy or political communities brag about the advances we’ve made through insurance coverage. But these increases have largely been through private insurer models that hamper access: There has been a sharp increase in the numbers of individuals in Medicare Advantage plans, which typically offer narrow provide networks while vastly overcharging the government through diagnostic upcoding and risk selection. States rely widely on private Medicaid intermediaries, which have significant provider network issues. Employer-sponsored private plans increasingly shift direct costs to employees through higher premiums, greater deductibles and copayments, and more aggressive prior authorization. Similarly in ACA marketplace plans. Thus, increased reliance on private plans is really an expansion of the problems that are peculiar to the private insurance industry, as revealed in the newest Commonwealth Fund Health Insurance Survey.

Promoters of these plans say that they are giving us freedom of choice by placing health insurance coverage in the marketplace, which touts competition as being an important mechanism for controlling costs. But look more carefully at the choices we supposedly have. Insurance category is dictated: Medicare by age or disability, Medicaid by poverty, employer sponsored plans by your job, or ACA plans or individual private market plans merely because no other choice is available. Many retirement plans mandate Medicare Advantage, and dropping physician payments in traditional Medicare undermine that option. Most of all, we have no choice about the higher non-clinical spending required by superfluous private insurance intermediaries, via profits, cumbersome administration, and administrative tasks forced on providers.

Besides, what choice do we really want? Don’t we really want free choice of physicians, hospitals, and other medical services – that would be available through an equitably funded, universal, public, single payer program, a program that belongs to all of us rather than just to the millionaires and billionaires, a program where all of our health care dollars are spent just on health care? I don’t think we really want a choice of private plans that are designed specifically to use what should be our health care dollars to create greater wealth for the intermediaries that find innovative ways of diverting our funds away from health care?

Look at the choice we made through the recent election. We elected a president who is choosing administrative personnel who intend to eliminate our traditional government Medicare program that is free of private carriers, and replace it with a universal private Medicare Advantage program which has already been demonstrated to divert hundreds of billions in health care dollars to their private industry. Furthermore, our president-elect has brought in the richest man in the nation who intends to manipulate our government in a manner that will make him the world’s first trillionaire. Is that the choice that we want? giving our health care dollars and other funds to the wealthiest individuals in our nation, while leaving out many of those with genuine health care needs that are inaccessible to them under our current system so reliant on private insurers?

Let’s give everyone the freedom of choice in selecting the health care that they need and want instead of having false choice of which intermediary is going to take much of our health care dollars away and leave too many of us without the health care that we need.

What is our choice to be? Profits over patients? Billionaires over health care budgets? Or patients over our own health care system that is designed to take care of everyone? It doesn’t seem like that is a very difficult choice.

New Government: Time to Revisit Single Payer?

Complexity in the US Health Care System Is the Enemy of Access and Affordability
JAMA Forum
October 26, 2023
By Larry Levitt and Drew Altman

Lack of insurance coverage, high costs, and poor outcomes are well-documented problems in the US health care system, and policies to address them have been hotly debated for decades. However, complexity is another under-appreciated problem that hinders access and affordability.

Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year (2022). The share increases to two-thirds of people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford.

The reality is that many people are hopelessly confused by how their insurance works. In Medicare, beneficiaries can now choose from an average of 43 private Medicare Advantage plans, and during open enrollment season, the airwaves are flooded with ads that may do more to confuse rather than illuminate. And people getting ACA coverage through healthcare.gov have a choice of more than 200 plan options on average. The complexity of too many choices can also lead to paralysis on the part of consumers.

Yet, any push for health care simplification inevitably clashes with commercial interests. The system is structured to simultaneously maximize profits, control costs, and serve customers, which are competing goals that add to the challenge of simplifying it.

 

Comment by: Don McCanne & Jim Kahn

Although Health Justice Monitor commented on this article a year ago, political developments have not only failed to provide significant improvement in our expensive but underperforming health care system, it appears that the malfunctioning of our system will only become worse.

We have been increasingly reliant on private insurers as demonstrated by the increase in conversion of traditional Medicare to private Medicare Advantage plans and the greater reliance on commercial plans through the Affordable Care Act. So we are spending ever more of our health care dollars on an industry with a mission that places a higher priority on diverting health care dollars to private investors instead of directing all of those dollars to achieving comprehensive health care for everyone.

We have an abundance of health policy research that demonstrates that the defective private insurance model increases costs and decreases access to care. It should be eliminated and replaced by a public single payer program that would, by design, not only provide health care for absolutely everyone, but also control costs while improving the allocation of health care dollars. That model would be similar to traditional Medicare except that it would offer more comprehensive benefits, eliminate cost sharing that currently causes financial hardship, assure free choice of providers and facilities, and equitably finance via progressive taxes which would be affordable for everyone without materially diminishing the lifestyles of the wealthy despite their paying more (they can afford to!).

In our recent presidential election, one of the major parties emphasized neoliberal policies which eliminated any consideration of the superior single payer model, instead supporting small incremental changes which would have negligible impact in healing our sick health care system. The other major party vaguely promised system improvement but hinted major cuts in public spending. They also selected individuals as likely heads of HHS and CMS who would shred the program that we have at a cost of lives, health, and worse financial hardship for patients.

Wouldn’t it be better set aside politics, and instead adopt policies that provide definitive solutions to the problems of high personal health care costs and financially squeezed providers? We have ample examples from countries of varied political leanings of how to use funds well.

Shouldn’t we encourage our legislators, all of them, to join together to approve a system that would work so well for everyone? Now that we have an incoming president who would like to take personal credit for radically redirecting government to serve the public, maybe we have a chance.

HJM with the US Political Shift

Comment by: Jim Kahn & Don McCanne

First, sincere apologies for the two-week lapse in HJM postings. We were consumed with worry leading up to the election, followed by shock and despair with the result. For those of us on the Left, the upcoming period is fraught with major socio-political risks and challenges. HJM readers no doubt feel similar intense and complex emotions.

Where does HJM fit into this new and fraught political environment? We’ve been contemplating this tough question.

Without a doubt, we need to keep monitoring the performance of current health insurance, which is likely to deteriorate with pursuit of the Project 2025 health policies. Other advocates do that exceptionally well, including HEALTH CARE un-covered on private insurer misbehavior, JustCare on Medicare issues, and PNHP laser-focused on Medicare Advantage.

HJM will still highlight discussing research and policy news that reveals the inefficiencies and inequities of our fragmented insurance system. We will, as always, get geeky in the interest of understanding the dynamics behind the news, and of making connections between issues. We will always analyze and educate about single payer / improved Medicare-for-All.

And, we will increase our attention to front-and-center political issues: How does single payer help us meet the current challenge to US democracy? How can single payer broaden support for progressive policies? How can it help heal the left-right political rift, by demonstrating the compatibility of efficiency and equity? How can we best convince skeptical right-leaning audiences of the common sense of single payer?

We welcome HJM reader input on refining our mission. What do you most value in HJM? What topics would you like us to address? How can we best support the struggle for health care justice, and invigoration of American democratic ideals? You can reply to the HJM email, or email healthjusticemonitor@gmail.com.

The Single Solution for a Myriad of Health Care Challenges

Perspective Roundtable: Critical Health Care Challenges for the Next U.S. President
New England Journal of Medicine
October 16, 2024
By Robert J. Blendon et al.

The next U.S. president, as well as Congress and state governments, will have to address some major challenges to Americans’ health and health care. On September 27, 2024, the Journal and the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health hosted a symposium exploring three critical topics: access to health care, affordability of care, and health and health care equity.

 

Comment by: Don McCanne & Jim Kahn

This NEJM article is quite long because it is a transcript of the entire symposium, but you should read it anyway because it represents where we are on the policy issues that currently impact our health care system in the United States, and where we should be going, in the opinion of these noted health policy experts.

So where do our policy academics and the government policy community stand today?

Much of the discussion you will be able to relate to since it addresses issues covered by the press and in the lay literature. You will find points with which you agree and other points with which you either disagree or which have not been addressed adequately by the policy community.

Since many of you are quite knowledgeable about health policy and the single payer model of reform, you will likely discover that most of the policy issues for which these experts have not provided satisfactory solutions can be quite satisfactorily addressed in a well-designed single payer model. We discussed this failure of health policy economists and other policy experts last week.

Our tasks:

1. Read the symposium transcript.
2. Join together with colleagues to create a short, bold explanation of what is wrong with our current fragmented system: most expensive among wealthy nations, nonetheless falling far short of providing high quality, affordable, equitable health care to everyone. And why: Rife with financial incentives that undermine the mission of a health care system. And, how we can fix it: describe simply how the streamlined and generous approaches in single payer should appeal to everyone, regardless of political affiliation.
3. Join with other individual advocates and organizations to deliver that message to the public at large. Use all the communication tools available to us, just like an election campaign: in person, in traditional media, in social media.
4. Inspire the public to use all communication resources, including direct contact, to persuade our legislators that this is the reform that we need and that we demand.
5. Rejoice as our president responds to the will of the people by signing legislation enacting a single payer, improved version of Medicare that will provide affordable, equitable, comprehensive, high quality health care for absolutely everyone.

Of course, we (still) face an uphill battle. Yet we must preserve and pursue this vision. We must eventually break through the US inertia and conflicts of interest, with so many other countries showing the way of efficient, generous, and effective health care.