Hospitals increase cost of health care...and pick and choose what they market to whom

The greed of pharmaceutical and insurance companies is the stuff of legend. There can be no justification for the huge costs that the American people have to bear as a result. Their administrative costs and profits alone are unconscionable and drive up the cost of health care so much that it takes a completely self-serving and willfully ignorant Democratic presidential candidate to disingenuously ask “how will we pay for” Medicare for All – and we  have a lot of them. The financial cost is, however, is not the most evil part of what they do. That would be the deaths and disability and bankruptcy that affects so many Americans because the insurance companies deny them care and the pharmaceutical companies make their drugs unaffordable. (This is a mild term for drugs that can cost $30,000-$100,000 a year and more!)

I have written about these issues many times. More recently I have also written about the role that providers (mainly hospitals and “health systems”, but also some physicians, nursing homes, etc.) play in the two-pronged scandal of the US health care system – too expensive and too unavailable to too many. There are some hospitals (I include “health systems” but will use “hospital” to avoid confusion with the “health care system”) that are actually for-profit, but most are officially “non-profit”. This means that they don’t have shareholders – and don’t pay taxes – but they otherwise behave just the same, trying to make as much money as possible. They say that they plow this back into the services that the hospitals provide, but it also includes salaries for C-suite executives that look just as outrageous as those in the “for-profit” sector.

More important, the “improvement” in services does not always – or even usually – create new services that were absent from the community previously, or make them available to more people than previously, say the poor and uninsured. They are usually efforts to attract insured, paying, profitable patients away from other hospitals by building a new, fancier cancer center, or heart center, or orthopedic center. Hardly ever pediatrics (except neonatal intensive care) or mental health – they only want to expand those services that are big profit centers. In this way, it is parallel to the behavior of drug companies; they prefer to minimally modify existing big sellers to get a piece of that market (“me-too” drugs) rather than to develop drugs to meet needs not currently being met.

It is good to see the hospitals being called out by major health system critics. Elisabeth Rosenthal, president of Kaiser Health News, wrote an important article on September 1, 2019 in the New York Times (where was once the health reporter) titled “That Beloved Hospital? It’s Driving Up Health Care Costs”, in which she makes many of the same points. She writes that

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

The reason, of course is the political clout that the big hospitals can buy (with, of course, our money!).The Democratic presidential candidates are beholden (with the exception of Sens. Sanders) to both hospital contributions and the role of big hospitals as major employers and economic drivers. “In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.” Could this have anything to do with why “The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia”? Ya think? Ask you politicians what they are going to do about it…

The media, including Kaiser Health News, has been running stories on hospitals that are aggressively pursuing lawsuits against patients who have been unable to pay their bills. On September 3, 2019, the Times ran a long piece on the poster child for this practice, Carlsbad Medical Center in New Mexico, in “As Patients Struggle With Bills, Hospital Sues Thousands”, but Carlsbad is by far not the only one. The practice is most common in towns with just one hospital, and of course, patients do not know how much they owe – or for what. It doesn’t matter if you are insured: “Ms. Price, 40, a nurse and local 4-H leader, has been sued five times by Carlsbad Medical Center, for bills totaling more than $17,000….Ms. Price said she had never received an itemized bill outlining exactly what she owed money for. The collection agency wanted the balance in full, and she was not able to work out a payment plan until after she was sued.”

This article names other hospitals that sue patients as a core business practice, and mentions over 20,000 suits in Virginia. Turns out that this was in no small part driven by the state-owned University of Virginia hospital in Charlottesville, documented by the Washington Post and MSN in “‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”. In a quick response, the Governor of Virginia and the University vow to stop suing patients, but this has apparently not affected those already sued: ‘“Fixing the problem “is complicated,” in part because “we are legally obligated as a state agency to collect debts,” he [UVA president Ryan] said. “But we have discretion within those legal constraints to make our system more generous and more humane.”’ It also has not hurt the CEO of the hospital “…Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president”. Maybe she can teach them to sue their patients…

Many of us have sort of emotional attachments to our local hospitals, where we were born, or delivered our babies, or had our life-saving surgery or other treatment; for which we raised money through bake sales and car washes, or maybe volunteered in the gift shop. But these are not the warm fuzzy hospitals you remember. Rosenthal acknowledges that many rural hospitals are in financial trouble – and they are – but supporting the fantastic (“non-”) profit of these major hospitals is not going to change that. As in every other sector of society, we have two classes of service. One is to those in major metropolitan areas with money or good insurance, with conditions that are highly-profitably reimbursed, like cancer. Preferably all of the above. There is no limit to what will be invested in them. Then there are those without money, or good insurance, who live in rural areas, or have problems that are not well reimbursed, like mental health or substance use. They will not get investment. Simple as that.

Major hospitals are big businesses and act like it. You are a customer – but, compared to other industries in which you are a customer, a particularly uninformed one. Need a car? A refrigerator? Financial services? Dental care in Mexico (had to get that one in)? You can find out what it will cost and compare prices. Hospital care? In the US? You gotta be kidding.

The answer? Improved an expanded Medicare for All, a single-payer system in which, as in Canada, hospitals get global budgets, and separate capital budgets so that they cannot use the money (profit) they earn on your care to build spas to attract high-paying patients from competitors. Where everyone gets the care they need, and no one gets excessive care. Possible? Too expensive? Ask the Canadians. Or Australians, where the average hospital bill is less than $800. Or British, or French, or Swedish, or Danish, or Dutch, or German, or Taiwanese….

"Medicare for All" means ALL -- Accept no substitutes!

Let’s start with the good news. “Medicare for All” is definitely trending. It is the central domestic issue for the Democratic primary. This is because of the absolute crisis in the health system. It is also, let us remember, because of Bernie Sanders, who has supported a single-payer universal health system for decades and made it a central part of his 2016 presidential campaign. He didn’t win the nomination, but he won the battle of ideas, which is why it is so important in this campaign.

People love the idea of being covered for their healthcare needs, and having that coverage untethered from where they work (assuming that where they work provides health insurance), whether they can work if they have been laid off, can’t find a job, or are disabled, or whether they are quite old enough to qualify for Medicare, whether they are quite poor enough to qualify for Medicaid (and let’s be straight, you have to be REALLY poor, even in the most generous states, and in some states it is just ridiculous). This is because the current healthcare system in the US really stinks. A huge percentage of those who are insured have terrible coverage, those who have reasonable coverage pay (often along with their employer) an extremely high amount for that coverage in premiums, deductibles and co-pays, and an unconscionable number of Americans are completely uninsured. The health outcomes in the US are terrible, trailing all other developed countries (discussed here many times). The only thing we lead in is the cost of the system, and of course the amount of profit made by the predatory components of it such as insurance companies, drug companies and some providers – which is of course totally related to why it costs so much.

An excellent example of the insanity of our current profit-driven system is provided by the Kaiser Health Network and covered by CBS Morning News and the medical news site “Medscape”, detailing how a dialysis patient received a half-million dollar bill because the dialysis center he went to, which was closest to his home (70 miles) was “out of network” for him. This particular patient will probably have his bill written off because of the extensive national coverage, but it happens all the time; it is the norm, not the exception. No wonder people are fed up!

The less good news is that, although most of the Democratic presidential candidates (notably excluding front-runner Joe Biden) have endorsed the words “Medicare for All”, their proposals are all over the place. Most of them do NOT guarantee universal coverage, not to mention the necessary expansion of benefits (“Improved and Expanded Medicare for All”) needed to ensure that the American people get ALL the health care that they need (including mental health, vision, hearing, long-term care, substance abuse treatment, etc.) The New York Times, which has made a crusade of limiting coverage of Bernie Sanders and trying to minimize or denigrate him when they do cover him, and is also an opponent of truly, universal, comprehensive single-payer health care, does have a very useful graphic in an article originally from the “Upshot” in February but in the print edition of August 13. It portrays the characteristics of many of the health plans proposed currently, and makes clear that only two, those sponsored by Sanders in the Senate and the bill in the House with Pramila Jayapal (D-WA) as the primary sponsor and over a hundred co-sponsors, actually would provide what we need.  

A clear exposition of many issues, including facts misrepresented about universal single payer, is summarized in an elegant piece in the Washington Post by Rep. Jayapal. It is an excellent point-by-point response to various criticisms and concerns that have been raised, and is well worth the time to read, even if you don’t have time to read the whole bill (Medicare for All Act of 2019).

Two of the most important criticisms to which she responds are particularly telling, since they are deeply tied. One is that people want to be able to keep their private insurance (presumably those who have, or possibly mistakenly think they have – good insurance). The “evidence” provided for this claim is that the percent of people who say that they support “Medicare for All” goes down if the question “even if you have to give up your current insurance” is added. Of course, the question is misleading; when people are told that they would be fully covered for everything, with no co-pays or deductibles or co-insurance, and that they will have completely free choice of providers, this objection goes away. Let’s be honest; no one cares about having a choice of which insurance company will deny them what they need; this is a nonsense concern. And, yet, this is driving the proposals of some presidential candidates and members of Congress to do a less-than-universal solution, some version of Medicare-for-More, or “buy-ins” or expansion of Obamacare.

The other objection, “how will we pay for it”, is also frequently heard, even from those who know how but just don’t want to accept it. The answer is very closely tied to the answer to the question above, because the cost only becomes impractically expensive if insurance companies – and their overhead and profit – are built back into the equation. A comprehensive Medicare-for-All program, when fully implemented, will be funded by the money that Americans and their employers pay for health insurance currently, including all the money spent by the federal government and states on Medicare and Medicaid, supplemented by additional taxes on corporations that do not already provide comprehensive insurance and on the wealthiest Americans. Yes, most people’s taxes would increase, but for the vast majority, the increase would be far less than they pay now in insurance premiums, co-pays, and deductibles, and would “buy” them comprehensive care for all medical problems with no limited ‘panels’ of providers. Those who would pay more can well afford it. But the key here is not having insurance company profit and overhead built into the system; this is one big reason that the US health care system is so expensive, and leaving it in makes it much less affordable. To suggest such solutions is like saying “the cost of business is so high, especially including payoffs we make to gangsters for protection -- but of course it is really important that any new system we develop include those gangster payoffs!”

Why would many pundits and “liberal” media outlets like the NY Times, CNN, etc. want to create such confusion and undermine efforts to create a truly universal, comprehensive single-payer system? I can’t know. I do know that they are all in the upper tiers of income, have good insurance, and are surrounded at work and in their neighborhoods by those in similar situations. Maybe this makes them blind to the needs of most people; maybe they believe that the top 10% of income of which they are a part is in fact typical. Or maybe they realize their privilege and want to keep it, and don’t want everyone else diluting their access.

But including everyone is key, not only for the financial reasons, but for quality reasons. When the upper income and well-educated are in the same system as the poorer and less empowered, they can be depended upon to ensure that the system is of quality, and this benefit then applies to everyone. It is why we cannot let them opt out.

Out health care system is a mess, delivering poor outcomes for lots of money, and is a maze of different programs and eligibility. We don’t need more of that; we need to simplify it and have one outstanding system that covers everyone.

Medicare for All: Still a great idea!

My last several posts have all had “Medicare for All” in the title. This makes one more. Maybe I am in a rut, or maybe it is simply the most important issue confronting health care in the US. Certainly there has been a lot written about it; just a review of very recent articles in the New York Times includes a wide variety. Conservative columnist David Brooks informs us that there is “no plausible route” to get to it, and we are told by Reed Abelson and Margot Sanger-Katz that there is “no precedent” for abolishing private insurance. The angst of the Democratic Party leadership in dealing with this newly-resurgent demand from its base is also discussed at length, with the Associated Press letting us know that it is a “divisive issue for Dems”. Robert Pear tells us about Nancy Pelosi’s plan to “expand health coverage” while being sure to not cover everyone. Of course, President Trump, not to be outdone (nobodyoutdoes the #Trumpenik!) has now announced his own plan, to completely gut and get rid of the Affordable Care Act and its expanded coverage. This is seen as a great gift to Pelosi, who needed something coming from way to her right, and now can “pivot hard” to fight to preserve ACA from the GOP rather than fighting with her own party’s progressives.

Of course, the Trump plan – get rid of Obamacare and then, well, don’t really have a plan after that, but it will be great – makes even a lot of Republicans nervous. Gail Collins has a particularly good time pointing this out, noting that

‘Republicans in Congress began desperately leaking the news that they had tried to talk their alleged leader out of the idea. The Democrats were almost swooning with joy. Really, Trump could not have made them happier if he’d announced that he planned to unveil a new tax cut called Help for The Greedy Rich.’

She also observes that the President has now moved from “who knew health care was so complicated?” to “I now understand health care especially very well”. Of course, he doesn’t – in fact, he understands it much less well than most policy makers, which isn’t very well at all, but he does understand how to both appeal to his base and please the wealthy folks who control the Republican Party, and indeed much of the Democratic Party.

It is frequently pointed out that many of the people who were most helped by the ACA, in particular its provisions that allow individuals to buy insurance at community rating, prevent discrimination against those with pre-existing conditions, and expanded Medicaid, are those in Trump’s base, and that eliminating the program and leaving another 20 million people without insurance might backfire. Paul Krugman’s column “The Republicans really hate health care” is accurate, and makes this point; for example, that West Virginia was promised better health care and more coal jobs. It has gotten only a few coal jobs, but 140,000 people stand to lose health care coverage if ACA is repealed. It remains to be seen if this will translate into folks voting against him and his minions, but I wouldn’t hold my breath. Although, even the Wall St. Journal has had an op-ed by Robert Pollin advocating for Medicare for All.

So what is it with the Democrats? The concerns that are expressed by many centrist, leadership Democrats about Medicare for All, or Universal Health Care of any kind seem to be in three broad areas: 1) Is it a good thing to cover everyone? 2) What will be the price Americans pay for universal health care? 3) Is this a politically feasible possibility? It is important to recognize that the fact that these questions are being asked at all, and that there is a significant portion of the Democratic congressional delegation who support Medicare for All, and that there is huge support among the American people, is YUGE. It is a testimony to how important health care is to us, to the fact that most of us are not buying the GOP line, and to the success that Sen. Sanders had and continues to have in raising the issue and continuing to focus on it.

First, is it a good thing to cover everyone? Answer: Yes. Everyone needs access to health care, and those who need it the most are often those who are left out of current, past, and future schemes for coverage – mainly poor, or near poor, people. It might be ok to leave some people out if those advocating it, advocating incrementalism, would suggest that the appropriate people to be left of were themselves and people like themselves, or the wealthiest, who can afford to pay their own way. But no, it is always the most vulnerable. And, anyway, there is great advantage to everyone being in the same system; the wealthy and powerful will ensure that the system works for them, and if everyone is in it together, it is more likely to work for everyone. The Times has a recent article about  Sen. Sanders saying “No to incrementalism”, which for some reason makes it sound like a bad thing. It is not. Certainly not if you and your family are being the ones left out by incrementalism!

Second, what will be the price? It will cost a lot to cover everyone. The numbers that even the sponsors of HR 1384, the Improved and Expanded Medicare for All bill whose primary sponsor is Rep. Pramila Jayapal of Washington, have put forward are very large. The thing is, though, the numbers that we spend NOW, by insurers and the federal and local governments (via Medicare and Medicaid and covering all their employees), and out of our own pockets in premiums, deductibles, and co-pays are far larger! And, of course, all this money buys us neither adequate health care for lots of people who are underinsured or have insurers denying claims, or good health outcomes. The US has for decades trailed the developed world in almost all measures of population health outcomes, and led only (by far) on money spent, both in total and per capita. Much of this money can be characterized as “waste” in the sense that it does not deliver health care to anyone, but is spent on high administrative overheads and profits for insurers and providers and drug manufacturers.

Third, is it politically feasible? This is an issue with lots of components. One highlighted by several articles in the media, such as the above-mentioned ‘Abolish private insurance: no precedent’ in the Times, are the jobs that will be lost in the insurance industry. And, although it doesn’t say it, in the offices of hospital providers who have armies of workers to fight with the insurance workers about payment. An expensive zero-sum game, except it is the people who pay. Sure, these are real job losses, but when has it been right to continue a bloated, non-productive industry that screws the whole country to protect jobs? I think never, but this is just a smokescreen for protecting profits. And HR 1384 actually contains funding for job retraining. The bigger issue for Democrats is money, money from big donors, as described in another NY Times article, ‘Even Liberal Democrats Can’t Quit Wealthy Donors and Their Big Checks’, although Sanders and Warren are the exceptions. In essence, “politically feasible” is always the one put forward by those who do not want big change to try to head it.

But there is great momentum from, you know, regular people, now. We have to keep it up and demand it from our legislators and candidates, and that will make it feasible.

Medicare for All, Compromise, and who gets left out

As the movement for Medicare for All gains steam, with the new bill, HR-1384, being introduced by Rep. Pramila Jayapal (D-WA) and 100 co-sponsors (video available on PNHP Facebook page), the attacks have, unsurprisingly, started coming. They are hard and soft, overt and subtle. The overt attacks on it from Republicans who call it “socialism” are probably the least important. They, and the folks for whom socialism is a buzzword that has them throwing up their hands in horror, were never going to support it or any effort to have universal health insurance, and are probably not going to support any less-extensive compromise. On the other hand, they could learn something by reading about the experiences of people in the all-the-other-industrialized-countries-in-the-world who have some form of universal health care. For example, the recent piece in the Washington Post by an American studying in Taiwan,  uninsured in either country, whose abdominal pain nonetheless led him to go to the ER at 3am. He was seen and given treatment in 20 minutes, had lab tests and imaging studies, was diagnosed with a stomach virus and given 2 medications, and sent off. Total cost: $80. (March 1, 2019)

The real threat, unsubtle and incredibly well-funded, is from the insurance and hospital corporations (and “non-profit” health systems) who are responsible for about 30% of all dollars spent on health care in the US being for administrative costs (including their huge profits) and not actually health care. They are a major cause of the high cost of health care in the US, and stand to lose the most if Medicare for All is implemented, because it will be funded in large part by taking that money away from them. Thus, they are highly motivated to attack any such attempt, organized to do so, and are already doing it, as clearly presented in Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’, NY Times February 23, 2019. This will ultimately be the real fight, incredibly wealthy companies that would lose a lot of money will do almost anything to keep it, even though it will prevent a change in the current crazy, costly, poor-result non-system that we currently have, that would benefit the health of all the rest of us.

The more subtle attacks, or perhaps “criticisms”, are from other Democrats and ostensibly liberal media, like the Times. Senator Bernie Sanders (I-VT) sponsors a single-payer Medicare for All bill in the Senate, S-1804, and many of the current candidates for the Democratic presidential nomination are co-sponsors, including Sens. Elizabeth Warren (D-MA), Kamala Harris (D-CA), Cory Booker (D-NJ), and Kirsten Gillibrand (D-NY), and Rep. Tulsi Gabbard (D-HI) is a cosponsor of HR-1384. Sen. Amy Klobuchar (D-MN) and Rep. Julian Castro (D-TX) are not. S-1804 is not quite as good or comprehensive as HR-1384 (the even-better successor to the old HR-676), but this is not the reason almost all of them (except, of course, Sen. Sanders) have stepped back a little from, or danced around, their position on a single-payer program in various interviews with the press. They worry it might go too far, and while want support from single-payer fans, they fear alienating others, or believe that Medicare for All cannot happen, and talk about compromise. Several senators have introduced another bill that would allow people over 50 to buy into Medicare ('Medicare for More', but only if they pay). The Times, however, is getting more supportive; in their February 16, 2019 editorial ‘How Much Will Americans Sacrifice for Good Health Care?’, they move to focusing on the cost and practicality, and no longer say single payer or Medicare for All is not a good thing.

Of course, other leaders of the Democratic Party do not even pretend to support Medicare for All, and cling to the falsehood that the Affordable Care Act (ACA) would be enough if the GOP had not let many of its components expire, and GOP governors had not refused to institute expanded Medicaid in so many states. The classic rendition of this song was performed by House Speaker Nancy Pelosi (D-CA), in an interview in a recent Rolling Stone. Dr. Don McCanne, in his great Quote of the Day, correctly says of Pelosi’s comments:

‘Perhaps most disappointing have been the responses of those who would prefer to continue to support the Affordable Care Act and add a public option - a Medicare buy-in for some…."All I want is the goal of every American having access to health care. You don’t get there by dismantling the Affordable Care Act." Further she says, "When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act." Has she been practicing composing Trumpisms? The Jayapal Medicare for All Act is vastly superior to ACA - absolutely no contest.’

“Compromise” is often touted as a good thing, and sometimes it is. Maybe it means you and your partner take turns deciding what movie to see or what to have for dinner. But often compromise is, as noted by business guru Stephen Covey, it is a “lose-lose”, where everyone gives up something they want. If we can find something that is “win-win”, it is of course better. Medicare for All might actually be a “win-lose”, a win for the American people (comprehensive health care for less money) but a loss of enormous profit for the big health and insurance corporations (no tears here).

The most obvious flaw in the logic of the mainstream Democrats is harping on the cost. Yes, it will cost a lot, but the average American family will pay less than they are now in premiums, deductibles and co-payments. The big saving would be in the elimination of the money being made by insurance companies, drug companies, and health systems, and apparently Speaker Pelosi is not ready to cut off their access to the trough. Already, the government pays almost 60% of all health costs (Medicare, Medicaid, coverage for government employees, tax breaks for employer contributions to health insurance, etc.) This means that, in our country, the government already pays more per capita than in most countries that cover everyone. Yes, HR-1384 would expand the benefits of Medicare (‘Improved and Expanded Medicare for All’) to be basically everything with no copays or deductibles, and this would be costly, but those of us who can afford it pay for them anyway, and those who cannot currently do without.

But there is another flaw. All of the folks advocating for less-than-universal-coverage, Medicare-for-More, buy-in to Medicaid for folks not poor enough to qualify now, let’s-not-let-the-perfect-be-the-enemy-of-the-good, are missing something. What they are missing is those people who are not covered or covered with poor insurance that won’t meet their needs if they are sick. All the compromise politicians and pundits seem to forget that these are real people, not just numbers (yes, if fully implemented the ACA covers 90%, but is that enough?). As I wrote in my very first blog post (“Universal Health Coverage”, November 28, 2008), ‘When was the last time, even in private but certainly in public, you ever heard someone say “I’m really suffering without health coverage, but don’t worry about including me and my family in your health reform plan. We don’t want to let the perfect be the enemy of the good.”?’ Those advocating for less than universal coverage need to get out there and tell us who it is that they don’t think needs good health coverage, who can be left out. You? Your Uncle George or Aunt Minnie? Your neighbor? Who are the Americans who they are advocating leaving out?

I can tell you one thing. It won’t be them or their families.

Venezuela and Medicare for All: Don't forget who benefits!

The mainstream media is not an evil, liberal-to-radical behemoth by any means. It is, however, often a willing, and sometimes self-deluded, ally and shill for the interests of the well-to-do in society, as well as for many questionable government policies. The latter is particularly important in the drumbeat buildups to wars, and is recently apparent in the coverage of Venezuela in journals such as the NY Times. The US government is making the case not only that Venezuelan president Nicholas Maduro is illegitimate because it has decided his election was “unfair” and “tainted”, as well as an evil and violent dictator, but that it will recognize unelected self-declared Juan Guaido as president. The Times has gone so far as to publish a self-congratulatory op-ed by Guaido, and it news coverage is typified by ‘Venezuelans Opposed to Maduro Pour Into Streets for Day of Protests’ and a Sunday Review piece by a Guaido supporter called ‘Venezuela’s Very Normal Revolution’.

I do not doubt that thousands marched against Maduro or that millions oppose him (or probably that millions support him). I certainly am not saying Maduro and his government is good, or that there is not justifiable opposition to his violent repression of opponents. I am not saying that revolutions are bad. I am saying that this one is funded and supported by the US government not because Maduro is bad -- the US has supported and continues to support dozens of brutal dictators around the world. It is because he is not ourdictator, not one who supports US policy, and this is critical because Venezuela is the country with the largest oil reserves in the world. As for the NY Times -- as with most leftist governments, the support for the one in Venezuela comes more from the poorest people, while those with access to the NY Times are among the most privileged.

And this is the connection to domestic health policy, and in particular coverage of the Democratic candidates for president’s positions on Medicare for All. The NY Times (and all mainstream media) is of course owned by the very wealthy, and as individuals they see the world as members of the class of which they are part. But, possibly more important, the editors and reporters are middle and often upper-middle class, and they see the world from this perspective, from that of their families, and friends, and neighbors who are – amazingly – also privileged! The people who have access to these editors and reporters are very skewed awayfrom the most needy, or indeed most people (who are not the same as most people in an upper middle class suburb).

In specific, we get essentially uncritical coverage of the statements of billionaires like Michael Bloomberg and Howard Schultz that “Medicare for All” is unaffordable, despite the clear fact that it is the current system that is unaffordable, and that a universal health system is going to cost less. One key part of this lower cost is the elimination of private health insurance companies’ profit, and their incentive to increase it by decreasing the availability of care. Yet the Times article covering Elizabeth Warren’s increasing iffiness on the issue contains phrases like ‘would people lose the choices offered by private insurance?’ That is, your ability to choose (maybe, depending upon what their employer offers) which overpriced-to-unaffordable policy, offered by which rapacious, obscenely-profit-making insurance company, to cover you so that, even after paying the premiums and co-pays and deductibles, you find out that, whoops, it doesn’t really cover what you thought it would or should, and you’re out of luck, and either have to pay out even more money you cannot afford or go without the health care you need. Wasn’t that what the insurance you bought supposed to get you?

Nope, not necessarily, and often not at all. The first goal of private insurance companies is to make a profit. That profit has to be maintained and expanded. The two major ways of doing so are 1) by raising the prices people (and their employers, if they are lucky enough to have employers who pay offer health insurance) pay, in premiums, deductibles, and co-pays, and 2) by denying coverage for care, or paying less for it, which often results in providers not, well, providing it to you. The insurers hire “pharmacy benefit managers” to get them the ‘best’ prices on drugs, often requiring your doctor to keep writing a different brand-name drug-of-the-month (again, see Danielle Ofri, “The Insulin Wars”), with the cost to you always going up.

What would Medicare for All offer? Or, more explicitly, Improved and Expanded Medicare for All, as in the House Bill that was H676 and will get a new number this year? First, everyone would be in the same program. No more shopping around for the least bad deal among the universe of bad insurance. Everyone would get the same benefits. The benefits would include all medically necessary health care: inpatient, outpatient, nursing home, home care, drugs, mental health, dental, eye care. Even hearing aids. Nothing excluded, except perhaps truly cosmetic surgery. Providers could not refuse to accept this insurance because they would have no business. Oh, maybe some doctors and hospitals could make a living caring for Howard Schultz and Michael Bloomberg and Saudi sheikhs who pay in cash, but there aren't very many of them, and so even the supplemental insurance we now buy would be unnecessary. There would be, you see, no deductibles or co-pays. Everything would be 100% covered. It sounds good. It would be good.

And it is not unaffordable. Currently, the government funds over half of health care (Medicare, Medicaid, government employees and retirees at all levels, military), and it is about 60% if you also count the revenue lost because employer contributions to health care premiums (unlike salary) are tax-deductible. The majority of the sickest and most needy (elderly, blind, and disabled) are already in Medicare. Most vulnerable children are in Medicaid or S-CHIP. To make up the additional cost, employers and individuals would continue to pay, but in taxes rather than premiums, co-pays, and deductibles, and for most (maybe not for Schultz and Bloomberg!) it would cost them a lot less. Most estimates of the excess costs in the US health care non-system are in the 30-35% range, for profits and administrative costs in the private sector (Medicare’s are in the 1-3% range). Administrative costs include insurance companies hiring armies of workers to deny claims, while providers have other armies to fight them, and demand more. This is money spent for no health benefit for the population, but it would be a mistake to minimize the extent to which those – insurers and providers and drug and device manufacturers – who are pocketing it would go to keep it coming.

Thus the role of the mainstream media, and the mainstream Democrats – to appeal to the needs (not desires, real needs!) of most of the people for health care and at the same time not threaten the wealthy and profitable sectors that can fund campaigns for or against them. Thus the concerns of “don’t people want to have their private insurance?” and even more ludicrous their choice of insurance company (“I’ve always been an Aetna man! So what if it costs a little more and I get just as little? I’m worth it!”). Thus the nonsensical pieces on how much a single payer Medicare for All program will cost, which ignore the cost of our current arrangement. And, somehow, manage to not address the fact that this current arrangement leaves concern for people’s health to last, and so doesn’t deliver it.

I understand that people are worried about change. But the cost, in dollars and health, of the current system has moved the majority of the population to want something different, something that meets their needs and costs less.  It is available, if we seek to do it, if we can resist the pressures from the industries and billionaires who profit from the current way of doing things.

When we read about the need to overthrow foreign dictators, or hang on to private insurance companies, we always must remember to ask: cui bono?

Hospitals post their charges: almost indecipherable, but important!

The recent Trump administration order to have hospitals post their prices has been widely covered in the media, along with both headlines and articles that make it clear that these prices list are far from…clear! For example, Robert Pear’s article in the NY Times on January 13, 2019, titled “Hospitals Must Now Post Prices. But It May Take a Brain Surgeon to Decipher Them” , starts:

‘Vanderbilt University Medical Center, responding to a new Trump administration order to begin posting all hospital prices, listed a charge of $42,569 for a cardiology procedure described as “HC PTC CLOS PAT DUCT ART.”

Baptist Health in Miami helpfully told consumers that an “Embolza Protect 5.5” would cost them $9,818 while a “Visceral selective angio rad” runs a mere $5,538.’

The Arizona Star piece on Tucson hospitals had a more moderate title, “Hospitals post prices, but public can find it confusing”, but made the same points. As a physician (if not a brain surgeon!) I think I can figure out what most of these mean, but the point that they are making is that they are hard for almost everyone to understand. The reason, of course, is that they have simply posted online their “chargemasters”, the price list that they supply to insurers (including Medicare and Medicaid), which are based on the nationally used “procedure codes”; these are numbers which identify different treatments that are abbreviated as above. So, the charge at Baptist for a radiologist injecting dye into an artery supplying your intestines is only a little over $5,000, while Vanderbilt charges over $42,000 to do a surgical procedure to close a shunt artery in your heart that is vital to fetal circulation but normally closes spontaneously after birth. The question is, what does all this mean? And what are you and I supposed to do with this information?

Elisabeth Rosenthal, the emergency room physician turned NY Times reporter turned editor of Kaiser Health News, is more optimistic in her Times Op-Ed on January 22, 2019, “Donald Trump did something right”. She acknowledges the opacity of the posted charges to most people, but says it is a great step forward, because they areaccessible, at least to those who are academic experts, and can be compared, both one hospital to another (“Maybe, just maybe, a hospital will think twice before charging a $6,000 “operating room fee” for a routine colonoscopy if its competitor down the street is listing its price at $1,000”), and to alternative treatments (“With access to list prices on your phone, you could reject the $300 sling in the emergency room and instead order one for one-tenth of the price on Amazon.”) Obviously, these would not be easily available on your phone now, but her hope and expectation is that third parties will develop apps that will take this nearly impenetrable information and make it easily accessible to people, as apps such as GoodRx® have done for drug prices. She emphasizes the magnitude of this change, since before now these prices have been closely-guarded secrets.

Rosenthal makes a number of other important points that illustrate the fact that this system is not only opaque, but deeply morally corrupt. Hospitals are run as businesses, to make money, even when they are ostensibly “non-profit”. Their CEOs and other executives are mostly businessmen, CPAs and MBAs – even when they are physicians, which sometimes happens, they are usually also MBAs – and are hired for their ability to run a money-making operation that happens to sell health care. And sell it, to your insurance company, at what often seems like deeply discounted prices because they are based on absurdly inflated chargemasters. “You don’t really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who’s going to pay full charges,” says one CEO. More important, it allows them to reach agreements with insurers to pay a lot less than the official “price”, which in turn allows those insurance companies to brag to you about how much money they saved you. Rosenthal notes this is farcical, raising prices to make you think that you got a discount (‘If a supposedly $1,000 TV is “on sale” for $80, it’s not really a discount. It’s an absurd list price’), and that it emulates practices in other arenas, such as airlines overestimating their flight times to make it seem like they have a better on-time percent.

At a higher level, Rosenthal points out what is wrong is that these inflated charges do make a difference. Your co-pays and deductibles, if you are insured, are based upon the amount that your insurer pays, so that if they have agreed to pay only 20% of the listed charge, $200 for the TV set instead of $1000, you still may pay more than if you bought it for $80 cash. And certainly more than if the insurer were paying 20% of the old list price, say $500. You pay. You always pay. (See, for example, how insulin manufacturers and insurance companies and pharmacy benefit managers, each following their own profit incentives, have made insulin – a life saving treatment for millions of people with diabetes – often unaffordable: Danielle Ofri, “The Insulin Wars”.)

And, of course, there is the nasty little glitch that it is the most vulnerable and most needy, those who are uninsured as well as sick, and often poor, that get charged the full list price, the $1000 for the TV, or the ostensible “uninsured discount”:

When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.

Wait. Medicare? Medicare would have paid a quarter of their list price and a third of what this uninsured person got billed with the “discount”? Yes. And that is a place to start. Hospitals – or the third-party app developers that will let you see these prices on your phone – should be required to list the Medicare-approved payment right next to what they will charge you, or your insurer. That would measurably increase the “light of day”.

Of course, some doctors and hospitals do not want to accept Medicare for this reason – they can charge more money to insurance companies, who pass it on to you in premiums (in addition to your co-pays and deductibles) while claiming to be saving you money. There is a solution to this also, although Rosenthal does not mention it. It is to have everyone in the same insurance program, a single payer, an improved and expanded Medicare for All. This would set the rates and pay them, without co-pays or deductibles for necessary services. Everyone in the same plan would mean that the better educated, wealthier, and generally more empowered would ensure that it worked for them – and thus would work for everyone else, middle-class, poor, and even homeless.

Yes, hospitals and other service providers (physicians, nursing homes, etc.) and drug companies and insurance companies would make less profit. I’m sure that your heart goes out to them (maybe the next requirement could be the posting of the salaries of the C-suite executives at hospitals…). But, after all, what the health care system should be run for, and is run for in every other developed country, is the health of the people, not the profit of corporations.

Amazing, huh? And it could be that way here!