Ron Dellums: Loss of a great leader and a job for the rest of us

On July 30, 2018, Ron Dellums, one of the giants of our era, died of cancer. As the obituaries in the New York Times and Washington Post make clear, he was a major progressive voice, inside and out of Congress, for many years. He was elected, largely on an anti-Vietnam war platform, in 1971 from “one of the most liberal districts” in the nation, Oakland and Berkeley, CA, and served until 1998. Over the decades he fought for women’s rights, civil rights, civil liberties, inclusion, anti-corporatism, fairness and equity, labor, and environmental goals. ‘He championed a progressive mantra: Stop war. Cut military spending. Help people. Address the nation’s social problems.’ He was a founder of the Congressional Black Caucus, and in 2007 was elected to a term as Mayor of the city of Oakland.

‘“So here comes this black guy from the Bay Area,” he told The Progressive magazine when he left Congress, “talking about peace, feminism, challenging racism, challenging the priorities of the country, and talking about preserving the fragile nature of our ecological system. People looked at me as if I was a freak. And looking back, I think that the only crime we committed was that we were 20 years ahead of our time.”

But, quite amazingly, neither the Times nor the Post obituaries, nor his extensive updated Wikipedia entry mention the issue that is the one that first comes to mind for progressives in the health care arena: his early and continuing support for a national health system, which he agreed was the most logical, effective, and cost-effective means of providing for the health care needs of the American people. The “Dellums Bill”, which was first introduced in 1972 and re-introduced at every session in which he served in Congress, would have created a national health system (not just a national health insurance plan) and was far more expansive than simply Medicare for All, although Mr. Dellums also supported that, and its current iteration, HR 676.Dellums’ United States Health Service Act actually proposed a comprehensive and rational health care system, with neighborhood health centers, larger multispecialty centers, local hospitals, regional hospitals, and referral centers, all joined to each other, all run by elected boards of consumers, and all funded by public funds. It would have been – and still would be – terrific for the health of the American people, and for controlling costs, to have such a system in place. Of course, it would not have been nearly as profitable for providers (which mainly means hospitals, but also doctors and others), insurance companies, pharmaceutical companies, device manufacturers, and other profiteers. So, of course, it never occurred. But Congressman Dellums continued to be a beacon for universal health care, and we should be ever thankful for his leadership in this arena.

Ron Dellums championed universal health care before Bernie Sanders was the spokesperson for it, although both supported each other, and remained a staunch advocate for it. Today we are still far from this goal, although the ACA did significantly expand access. Although its opponents have not succeeded in repealing it, they have done what they could to make it less effective in covering everyone, including removing the individual mandate, removing funding for many of its programs (such as navigators), limiting access to the individual marketplace (although as many people signed up in 2017-18 with only six weeks to do it as in 2016-17 with 12 weeks, attesting to its popularity), and other reactionary efforts. But the ACA was not universal health care, nor was it an effective way of controlling costs. It expanded coverage, but did not redesign the health system the way the Dellums Bill would have.

With control of the government in the hands of Republicans, including not only the self-designated populist and reality TV figure who is President, but a Congress and state governments in the hands of a GOP who manifest no semblance of humanity. As noted accurately by Thomas Frank in The Guardian

‘Republicans are a known quantity. Their motives are simple: they will do anything, say anything, profess faith in anything to get tax cuts, deregulation and a little help keeping workers in line. Nothing else is sacred to them. Rules, norms, traditions, deficits, the Bible, the constitution, whatever. They don’t care, and in this they have proven utterly predictable.’

Certainly they don’t care about the American people’s health, which is suffering worst in the reddest counties in the US, those that have also suffered the worst from stagnant wages coming from the pro-corporate policies of the GOP, as well as environmental degradation. We need to continue to work to change these policies, to un-elect Republicans, to elect people who stand for progressive change and not pro-Wall St status quo like the DNC.

While we will not be able to re-create him, we need more people who seek to be like Ron Dellums.

Stop war. Cut military spending. Help people. Address the nation’s social problems.

Is the US health system about "health" or "profit"?

There are two forces at work in the system of health care delivery in the US which are essentially incompatible. One, which might be called the “health” approach, is focused on improving the health of the people. This could, should, and does include efforts to control costs, because this makes it possible to maximize the number of people who can benefit. This approach, which is codified in almost all international and most national health goals, seeks to use whatever resources exist (financial, structural, institutional, and human) to have the greatest health benefit for the most people. The World Health Organization (WHO) defines health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. A cornerstone of this is understanding that public health measures, which benefits populations, are generally of greater urgency and wider benefit than individual medical interventions.

While the need for a public health approach is perhaps more obvious for poor countries which lack, for example, clean water, it is no less important for wealthy nations such as the US; we just don’t usually think of the fact that we usually have clean water as a “health benefit”. As with many things, we are less likely to notice things that are good than those that are problems, and we relegate them to the background of our consciousness. We don’t wake up each morning saying “I’m glad I don’t have cholera because I have access to clean water!” Indeed, it is only when we travel abroad and have to use only bottled water, or when a crisis like the lead pollution of the water supply in Flint, MI grabs our attention, that we give this any thought at all. The result is that public health efforts pay the price; less than 6% of our US health expenditures are on public health, with the bulk spent on direct individual medical care, and the profit that insurers, providers and middlemen skim. In addition, our country spends much less, proportionally, on efforts that impact upon the social determinants of health, those characteristics of people’s lives (housing, food, safety, education) that affect people’s lives much more than health care.

Still, when we – or those we love – are sick and in need of medical care we are grateful that it is there. But for many or most of us, it is often hard to pay for it. When we cannot, when the incredible amount of money we have to pay for medical care (often even when we are insured) threatens our families’ well-being, our ability to pay for shelter, food, education, it is a different story. And we know that access to and use of such individual medical care is neither randomly distributed among the American people nor allocated based on the greatest need; no one is shocked to discover that rich people get more medical services. (What may be shocking to learn, however, is that this does not always lead to better health. Services are often delivered -- to those who can pay -- whether they are really necessary or not, and sometimes this leads to complications and worse health!)

It is in this context that a new study in the journal Health Affairs by Dickman, et al., “Health spending for low-, middle-, and high-income Americans, 1963–2012”[1]is very revealing. The authors provide data on both the amount health spending among the American people over that 50 years, and how it has been distributed by quintiles of income. To summarize the findings: in 1963, before Medicare and Medicaid, spending was heavily skewed toward wealthier populations, but after those programs were implemented spending became more equal among the quintiles (although, adjusted for disease burden, which is higher in low-income populations, it was still not equitable). Then, over the last decade studied, the spending gaps returned, with much more being spent on the upper than lower quintiles (despite the generally better hea

lth of those who are better off), for the population under 65 (presumably because those over 65 all have Medicare). The authors state that “The rising income-based disparity in spending suggests a shift from allocation of health care according to need to allocation by willingness (and ability) to pay,” and it clearly does. They add that “It is unclear whether this shift arises from the underuse of needed care among the poor or overuse of unnecessary care by the wealthy,” but I am going to go out on a limb and suggest that it is both.

The reason for this is the prominence of the second force at work in health care systems (you were wondering if I would ever get to this!), which I will call the “profit” approach. This approach looks at health care as a commodity to be purchased and marketed. Unsurprisingly, those taking this approach choose to preferentially market both certain services over others (those for which the reimbursement is much higher than the cost of providing them, called even in non-profit institutions the “profit margin”), and market them to certain populations over others (those with money or insurance, and relatively good health so there are less likely to be costly complications). While this approach tends to favor the wealthy, leading to the data presented by Dickman et al., it also favors the less sick. Since older people tend to be sicker than younger (and are covered by Medicare, which pays less well than private insurance), this may in part explain why the quintile-of-income differences are less for the elderly. In summary, health care providers (mainly hospitals and physicians, but also others), want to market the services on which they can make the most money to the people who, arguably, need them the least. You can have greater difficulty accessing care because you are the wrong person (too poor, too sick) or have the wrong condition (one for which treatment has a low profit margin).

Dickman and colleagues present their data fairly dispassionately, without hammering home the obvious conclusion that it reflects a society more driven by the “profit” than the “health” approach to health care delivery. Essentially, it is a story of half-hearted (called “practical” by its advocates) efforts to introduce greater equity into our health care system being overcome by the tactics that smart and well-paid insurers and providers employ to “game the system”. In his regularly outstanding “Quote of the Day” commentary on the Dickman article, titled “Redistribution of health care from the poor to the wealthy”, Dr. Don McCanne takes the discussion a little farther, noting that a single-payer health care system, in which everyone had the same coverage and which could regulate the marketplace, decreasing the profit incentive, would improve the population’s health.

When I wrote to Dr. McCanne that the effort to find ways to preferentially deliver high-profit care to well-insured high-income folks rather than those who needed it most upset me (OK, I said it made me want to puke), he wisely responded that it “seems like our health care system has excelled at creating ‘work arounds’ for those measures that health care justice advocates keep attempting to advance.”Usually when people use the term “work arounds” they are referring to finding ways to do what needs to be done in the face of bureaucracy or inefficiency. In this case, however, it means propagating inequity in order to make money.

The two different approaches, putting “health” or “profit” as the primary impetus to our health care system, get different results. Personally, I favor “health”. Sadly, though, the other is often more prominent.

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[1] Dickman SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU, “Health Spending For Low-, Middle-, And High-Income Americans, 1963–2012”, Health Affairs 35(7):1189

The US health and social service system is evil

I have often written about how our health system is “deeply flawed”, but I realize that there are many ways in which this is a grand understatement. I initially intended to call this piece “health insurance companies are evil”, but realized that this singled out but one player. I mean, insurance companies are at least as evil as other parts of the health and social services sector, but naming only one part both does a disservice to that part, which is acting rationally in relationship to the other aspects of the system, and tends to forgive the others.

The thing wrong with our health system is that it is a mess; there are dozens or hundreds of ways to have health insurance coverage, or not, and each costs a different amount and covers different conditions, for different percentages, with different amounts of coinsurance and co-payment and deductibles. A single-payer health system, where everyone is covered with the same benefits for the same care (all that is needed, none that is not) and payments tiered to income, is the only rational and effective way to make sure that we have the possibility of quality health care. There can be no quality without equity. While I will not spend more time here making this case, because I and others have previously done so extensively, I will refer to it.

What is evil is how the system affects our actual people. However, people are not really ever seriously considered in “health reform” (or social service “reform”). Yes, people’s suffering sometimes gets mentioned by political candidates, who note that some people are paying too much or are not getting care. Indeed, this has been a big theme of Republican candidates who are critical of Obamacare, but whose only plans are ones which will make it a lot worse for most people. Actually making the system work for people is never really on the table, because when the political negotiations begin, the big players (insurance companies, providers, drug companies, device manufacturers, etc.) enter the picture.

Let’s get right down to it: people in the US, even those who are citizens, just do not get the coverage and services to which they are fully entitled, not to mention the coverage and services that they actually need. You have to sign up for Medicare, pay for Part B (which is what covers everything except inpatient hospitalization, including doctors’ fees), choose and pay for a Part D plan. If you are lucky enough to be able to afford one, you have to look through a maze of possible Medicare supplement plans and hope you chose correctly, given the multiple variables of your health status, the benefits profile, where you live, your actuarial as well as self-perceived probability of getting ill, and what you can afford. Even Social Security, a benefit that you have paid into for your entire working life, requires you to sign up and show you are eligible. This is nonsense; there is no reason it should be this way. We start with a non-system that does not cover everyone, provides inadequate coverage for those who do have it, and makes it difficult to sign up, presenting numerous obstacles which allow people to fall through the cracks.

Actually, this is more than nonsense; to the extent that people pay the price of inability to navigate the system with their health, it is evil. It would work, and be much simpler, if everyone, when they retire, got Medicare. And if Medicare covered everything for everyone wherever they live. Why not just make sure everyone gets Social Security? Why make it the responsibility of the person to demonstrate that they not only are truly eligible but that they can get through a jungle of options, often confusingly computer based, when they are getting to the end of their careers? Of course, if we had a single payer system, everyone would be in and there would be no change when you retired or became 65; you’d already be in a system in which everything you need and nothing you don’t need is fully covered.

Actually, in a good system you’d be better than “fully covered”. You’d be covered appropriately; you would, whoever you are, get the care that you need, but you would not be eligible for coverage for things that you don’t. We would have a health system that provided necessary, appropriate, and proven diagnosis and treatment for people, rather than emphasizing the provision of services which were most profitable to the providers. Insurers would not do their best to risk-select, would not be able to charge more for some people than others (and they can under Obamacare; they have to cover you even with a pre-existing condition, but can charge more), and would not even have to be for-profit. I favor a single-payer health care system such as Canada’s, a (fully-funded) Medicare for all, as does Sen. Sanders. But there are other reasonable alternatives; Switzerland, for example, has, instead of a single payer, multiple insurance companies. But these companies have to cover everyone, provide the same benefits, charge the same price, and be non-profit.

Critics of Sen. Sanders often say that a Medicare-for-All system would bankrupt us. This is also nonsense.  It presumes the built-in profit for insurance companies. It presumes that we would continue to pay the most of the most complex and high-tech procedures, and let providers (via the complex system of the RUC --  Changes in the RUC: None…How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, which essentially sets the Medicare rates on which all other payments are based) set the rates for their own procedures. The evidence is in every other wealthy country, all of which spend much, much less on health care and have much, much better outcomes. They also provide much better social services, not only for the needy and the poor, but for everyone. Retirees get their pensions. And they keep their health care.

The system works in these other countries; that is, if your interest is in ensuring that everyone gets the health care they need, the pension benefits to which they are entitled. If your interest is in maximizing the income of (some) providers and the profit for insurance and drug companies, then they don’t work as well. So I guess our system is not necessarily evil, it depends upon your values.

But, then, I would argue that the values on which the system is de facto based, though, are evil ones.