Health Justice Monitor Annual Review 2022

In this guest post by my colleague Dr. Jim Kahn, he covers a broad range of US health policy issues. A version of this post also appears on his website: HealthJusticeMonitor.org. You may not agree with all his points, but that’s the beauty of Sensible Medicine

Vinay Prasad MD MPH

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Health Justice Monitor Annual Review 2022

Summary: Profits, insurance gaps, and medical debt are high; access to care and longevity are low; and efforts for real reform remain determined and align well with democratic values.

Revelations – What did we learn (or learn again)?

Our system is failing, more clearly than ever: The US insurance patchwork is an abysmal failure. The Commonwealth annual survey found that 43% of adults 19-64 are inadequately insured; 46% skip care for financial reasons; and 42% have medical bill problems or debt. Underinsurance among children grew from 31% in 2016 to 34% in 2019, a rise of 2.4 million. Women of reproductive age are more likely to skip or delay needed care due to costs, and have the highest rates of avoidable death among high-income countries. More fetuses and babies are dying from syphilis, due to inadequate prenatal care. 26 year-olds struggle to find coverage. A reporter battled with prior authorization to obtain his insulin, barely.

Only 21% of US adults think our healthcare system is good or excellent; just 7% for costs, 22% for equity, and 31% for access. 

Most sadly, overall mortality strikingly worsened: longevity dropped from 79 in 2019 to 76 in 2021, placing the US 4-8 years of life expectancy behind other wealthy nations.

Medical debt is surging – currently affecting 41% of adults, median $2500 with significant effects on other needs. Other surveys found that 18% of households have it, worsening social determinants of health, and 1 in 4 Gen Z and Millennials skip rent or mortgage due to medical debt. Privately-insured individuals with chronic illness are far more likely to have medical debt that is delinquent or in collections, and credit problems. At its worst, medical debt combines with loss of access to care. Not-for-profit hospitals aggressively pursue payment from poor patients eligible for free care. The prevalence of debt in collections varies geographically, higher in the South and with elevated levels of multiple chronic diseases, low birth weight, uninsured, Black race, low income, and high medical spending. The centrist proposed solutions are grossly inadequate.

Health workers feel the pain. The electronic health record, laden with billing requirements, consumes >4 hours per day of physician time, far higher than in countries with simple insurance. There was an exodus of health care workers due to COVID-related work stresses and inadequate employer support. 

Our priorities are profoundly skewed. A nurse who mistakenly kills one patient gets 8 years in prison; our insurance gaps kill 100,000 a year and nobody is indicted. Primary care, which saves lives, is struggling to survive.

COVID revealed & exacerbated the problems.  During the pandemic, COVID-revealed insurance flaws went unaddressed. Sadly, lack of insurance caused 340,000 added COVID deaths (at time of analysis, more since), radio interview here.

Racial and income disparities remain pervasive. Racism is widespread in US health risks & care, including lower payments for hospitals serving black patients. We propose that single payer will meaningfully (but incompletely) mitigate it. Racism even appears in the crafting of the Inflation Reduction Act. A tiny but vocal group of doctors argued to end all COVID precautions (including masking) which would most harm under-vaccinated and -resourced populations.

State-manipulated and privately managed Medicaid is floundering. In California, a new private pharmacy carve-out adds costs and impedes prescription filling. Medicaid does not guarantee access to cancer care. The profound complexity fills the news. When Connecticut Medicaid dumped private insurers, they saved money and raised quality of care.

System tweaks fall short. Value based care (VBC) – e.g., accountable care – is a pretext for privatization and shareholder yield, with no evidence of public financial or health benefit. Paying for quality targets has not improved quality, with countless dollars and hours on metrics of dubious validity. We critique the CMS manifesto for VBC. Unfortunately, moderate Dems and the GOP support privatization with regulation, a proven non-cure for our insurance woes.

Responses to COVID insurance loss staunched the bleeding briefly. The end of pandemic-instigated Medicaid expansion means eligibility “redetermination” will remove up to one-third from the program. Expanded ACA premium subsidies were insufficient and temporary. As the COVID crisis subsides in intensity, special funding to support its care is disappearing, with patients uncovered.

Medicaid expansion in California leaves behind hundreds of thousands of immigrants.

Health savings accounts – an ever-so-clever invention – turn out to be regressive and ineffective (as many of us predicted). High cost sharing benefits insurers and harms patients. Price transparency for hospitals is rarely adhered to and futile. Piecemeal actions to lower administrative costs are a false fix – untested and small in magnitude. We imagine an apology from a health economist realizing his misguided faith in system tweaks.

A growing profit focus is largely to blame: We determined that an apparent 4.5% insurer profit margin really represents massive 30% returns. We see corporate myths and profit models adding complexity with no gains for patients. The Elizabeth Holmes Theranos case reminded us vividly of the corrosive role of greed in creating false health benefit narratives, as seen broadly in health care. Twelve-year financial trends for the largest six insurers reveals skyrocketing revenue and profits, based mainly on a growing role in public insurance. Half of Americans are in their plans. Private insurers boosted profits during COVID by keeping premiums for care not delivered, even as the government bailed out providers. Income-seeking tactics following business norms rather than medical ethics hurts patients.

For-profit companies are buying up primary care (and here), gastroenterology, and providers more generally, raising serious concerns about the effects of a profit model and lack of community control. Amazon joined the fray. Investor ownership of hospitals is linked with more low-value care, while higher primary care physician presence predicts less low-value care. Sadly the big money culture spreads: both for- and not-for-profit hospitals use aggressive business models (mergers, high prices, & marketing of lucrative services) to maximize revenues and enrich executives and specialists.

The accelerating intrusion of private equity is profoundly damaging (and here), like termites weakening the structure of US health care, rewarding investors at the expense of patients. Private equity ownership of nursing homes depletes services and raises mortality. In the UK private for-profit care raises mortality.

Rising public support for unions is a counterpoint to salary cuts for pharmacists.

The profit quest of course afflicts drug companies, with stunning profit margins. Pharma is battling insurers. And they’re manipulating prices to maximize profits and patient burden.

We bemoan the pervasive untrammeled focus on profit over basic social values, with guns, corporations, foreign policy, and health care.

Medicare is under attack. Medicare continued to suffer the ravages of privatization, from Medicare Advantage (MA) to Direct Contracting in Traditional Medicare (TM). Whistleblowers and the government fight fraudulent upcoding by MA plans, but CMS egregiously fails to correct aggressive (largely legal) upcoding, overpaying by $600 billion over 10 years. MA plans inappropriately denied millions of prior authorization requests. A second installment by Drs. Gilfillan and Berwick buttresses their Sept 2021 critique of MA. Another litany of MA failings.  The NY Times exposed the MA “cash monster” absconding with public funds. MA engages in aggressive and misleading marketing. Compared with TM, clinical outcomes are worse for advanced cancer and similar (at best) for myocardial infarction. Despite cogent critiques, CMS only tinkers at the edges with hundreds of pages of regulations that ignore the fundamental problems.

In February, CMS rebranded TM direct contracting (DCEs) as ACO REACH, leaving intact its profiteering core structure. We critique its defense here and here. And ponder and worry about its risk rating framework. TM physician payments are dropped, leading to program exit. TM ACO REACH will further undermine doctor-patient trust, and won’t provide meaningful equity gains.

Resolve – How did we demonstrate ongoing broad commitment to single payer?

Broad public insurance works. Veterans Affairs (basically a small national health service) lowers mortality by half and costs by 1/5 after an emergency visit, compared with private care. Our analysis of proposed financing for California’s AB1400 suggests savings for the vast majority of families, and a new online household cost calculator lets individuals see for themselves (preview: 9 in 10 save an average of nearly $6000).

Public discussion about reform retains a robust single payer component. Single payer has a clear definition, regardless of what critics may say. A commentary in the Nation noted $117 billion in annual savings from single payer in California amidst our health care cost explosion and the unsavory trade-off forced on us daily: corporate profits up, family health down. Voters across the country approved local single payer initiatives and midterm ballot measures for universal publicly administered health insurance, as well as to regulate medical debt collection and expand Medicaid. A third of adults would vote for a candidate from a different political party if reducing healthcare costs was their top priority. We featured two inspiring women, a lawyer pursuing drug patent changes that favor access for patients over stockholder gains and an heiress urging high taxation of inherited wealth. Don Berwick, a pre-eminent leader in quality improvement, endorsed single payer over greed and profit.

The Healthy California for All Commission endorsed “unified financing,” standard coverage indistinguishable across individuals, lowering costs while assuring access; aka single payer. The Congressional Budget Office highlighted multiple ways in which single payer would strengthen the general economy. Indeed, the thriving economy of Taiwan adopted single payer in the 1990s. We saw single payer support from a conservative acquaintance, a well-known libertarian, Ross Douthat, and a lifelong conservative in Utah. California’s AB1400 advanced from committee, but alas with inadequate support to pass In the full Assembly, was pulled; we explored potential lessons.

Mainstream Democrats passed some good if minor reforms. The Inflation Reduction Act, a scaled-down Build Back Better, takes baby steps toward single payer: first-ever controls on drug prices for CMS and out-of-pocket costs for Medicare beneficiaries.

Health reform is linked to other health issues. We note the rising tide of gun deaths in children and advocate for truthful discussion on guns to honor those who served in the military. We oppose the loss of abortion rights, linked to health reform and democracy. We highlight the profound health implications of climate change.

Robust democracy & single payer have important links. Challenges facing democracy parallel those in health care – a controlling minority aggressively, undemocratically, and fraudulently persuades legislators and bureaucracy to do its bidding. Tactics used by the GOP to subvert voting and for-profit insurers to subvert health care are remarkably similar. The successful midterms (for Democrats and democracy) prompted exploration of conceptual and strategic links with single payer. Indeed the battle for the soul of health care echoes – or should – the battle for the democratic soul of the nation. We can fight conservative despair politics with single payer. Voting rights bills and single payer use simple & equitable rules to guarantee the rights to vote and health care. Freedom is a central feature of single payer – to choose providers, prevent medical debt, and avoid billing hassles. Many wealthy countries thrive with social democracy, crucially enabled by universal health coverage (just reaffirmed in British Columbia). 2022 saw democracy protected from tyrants in the US and abroad through visionary leadership and resolve; the struggle for US health justice demands nothing less. The Jan 6 hearings offer a model for effective public hearings for single payer.

Alternative framing is useful, and fun. We listed 20 single payer advantages & 20 obstacles. We highlighted a call for skilled advocacy. We demonstrate that single payer is “free love”. Two video minutes with Dr. Glaucomflecken says it all, with a smile. We report on disintermediation – insurers pulling out, alas an April Fools post. The profit-mortality nexus is clear on Halloween.

We mourned the passing of Paul Farmer, a visionary and unyielding advocate for global health, who’s antipathy to limiting care is so relevant to the US single payer discussion. We explore the idea of “health communism”.

We praised Thomas Piketty’s vision for modern socialism, which embraces public-spirited investment in health and education for all, while adopting modern equity and ecological values.

Resistance – Where did we fight back against anti-reform actions?

We pushed back on the myth that fee-for-service is the high medical cost culprit and capitation is the only solution. We critique the distorted single payer variant Medicare Advantage for All. Advocacy organizations argued to completely overhaul or dump Medicare Advantage, and battled ACO REACH. Connecticut advocates fought anti-competitive hospital price gauging.

In sum, a 2022 triptych mnemonic:

1) Private insurers (and pharma and large providers) grow profits via manipulation;

3) Even insured patients face huge costs that compromise access & health, and confer crippling debt;

3) There’s strong popular support for fundamental reform – single payer.

The struggle for health justice continues.

- Jim Kahn, Emeritus Professor of Health Policy, UCSF; editor, Health Justice Monitor.

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