Health care is expensive in America because it profits those with power

In this excellent review of the late Uwe Reinhardt’s book “Priced Out,” Dr. Adam Gaffney lays out in cogent terms why we cannot understand rising health care spending in America in simple terms of either over-utilization or insurer-provider price negotiation.

This writing is especially impactful to me because I became interested in health care due to frustration with how high health care prices were keeping people in poverty from getting the care they needed, and was initially very persuaded by super-utilization arguments. I followed the work of people like Jeffrey Brenner because at the heart of it, I saw compassion for patients harmed by lack of preventive care and social services. However, I also absorbed the subtle patient-blaming aspects of this approach.

In medical school at UPenn, I got involved in excellent research by Heather Klusaritz through which I had the opportunity to interview patients who had been labelled at super-utilizers due to frequent visits to emergency departments. In these conversations, I was forced to confront my internalized bias against these patients who were described as “inappropriately” visiting emergency departments for complaints that were not true emergencies. Through these conversations, I gained a deeper understanding of the inadequacy of our health care, public health, and public welfare infrastructure. If frustration with these systems led me to medical school, it was in medical school that I saw just how bad things really were.

With faculty like Zeke Emanuel providing our health care systems lectures, I initially bought into neo-liberal arguments that these were simply failures of incentives. Part of me believed that if enough Ivy League technocrats crafted just the right policies–Rube Goldberg-esque as they might be–private insurers and for-profit hospitals would provide for the health care Americans needed. However, over time I began to see how market forces would never be sufficient to guide health care allocation and development, and it will only lead to ever-rising health care spending at the expense of everything else in our budgets.

For both the private insurers and profit-driven hospital systems, increasing health care spending is just more cash in their pockets. Your deductible is their kid’s private school tuition payment. Health care isn’t expensive in America because of utilization. Health care is expensive in America because it profits those with power. There is exactly one real policy solution to the fact that we now pay nearly $11,000 per year for health care in America compared to an average of $4,000 per year in OECD countries and that solution is single-payer Medicare For All.

High health care spending in America means lower wages for Americans. It means high deductibles, frequent medical bankruptcies, and families rationing health care because they need some money for groceries. It is inhumane and we’ve tolerated it for far too long. As long as private insurers are the payers in the American health care system, there will always be insurance trolls whose priority is to deny cancer patients their chemotherapy or to put huge paperwork burdens in front of patients and doctors to discourage necessary care. As long as private insurers are the payers, hospital systems will spend enormous amounts of money on flashy branding and sleek buildings to attract wealthy patients as if a person’s income determined the value of their life.

So read Adam Gaffney’s piece and vote only for those politicians who support Medicare For All because it is truly our only way to a better future for health care.

Medicare For All: An Update

A little over a year ago, I made my personal case for Medicare For All. In that post, I argued that the American health care system has intolerable financial toxicity on patients and that a transition to a single payer system, such as Medicare For All, was the only feasible way to achieve true universal health care coverage in which a person’s economic status was not the main determinant of the health care they receive.

Since then, Medicare For All has continued to gain momentum with many of the leading contenders for the Democratic presidential nomination like Bernie Sanders, Elizabeth Warren, Kamala Harris, Cory Booker, and Kirsten Gillibrand explicitly in favor of this approach.

Pramila Jayapal (my very own congressional representative) has released an updated house bill (H.R. 1384, summary here) with 108 cosponsors, to implement Medicare For All. This operates as a companion bill to Bernie Sanders’ Medicare for all bill (S.1804) with 16 cosponsors in the Senate.

As coverage has increased, I’ve seen some important points about Medicare For All go missing from the popular discourse, so I would like to highlight a couple of points here.

What will the quality of coverage be like?

Although I feel that overall “Medicare For All” is a great slogan, it sometimes creates confusion because many assume that this means that the current Medicare plan would simply be extended to all Americans. However, the Jayapal and Sanders bills both outline a heath insurance payment system that is far more generous than current Medicare. For that matter, it’s far more generous that most commercial insurance. We’re talking no copays, no deductibles, unlimited network, vision benefits, dental benefits, and long-term care benefits. For the patient, this means that if the health care is medically indicated there are zero financial barriers to you receiving it.

How are we going to pay for it?

Many commentators have brought up that the budget allocation for a Medicare For All bill, by nature of paying for all Americans’ health care, is quite large. However, when compared to current national health care spending, the increase is marginal. For example, using estimates from The Urban Institute, annual health spending would increase from $2.8 trillion per year to $3.5 trillion per year.

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That additional $500 billion gets 34 million more Americans medical coverage, 75 million more dental coverage, and 167 million more vision coverage. That is in addition to upgrading every American’s health care coverage as described above. There are a variety of ways to pay for this including repealing Trump-era tax cuts ($230 billion per year) and implementing a wealth tax ($275 billion per year). Matt Bruenig has also laid out how to capture current employer health insurance spending through payroll taxes.

Advocacy versus legislative action

It’s worth emphasizing that Medicare For All is still in the advocacy stage, not in the legislative stage. Although a majority of Americans already support Medicare For All, activists and advocates are working to build upon that strong momentum and build enthusiasm amongst legislators who can bring Medicare For All into reality. Not every nitty gritty detail is going to be exactly worked out at this stage and that’s okay. Good quality legislation takes time to build and refine. It often requires ongoing amendment after passage. We as a nation have proven ourselves capable of this in the past and we can continue to be capable of it as long as we remain committed to universal, comprehensive health care coverage that is free at point of service.

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The U.S. government spent 50 million dollars on research which showed that Truvada, an HIV medication, was safe and effective at preventing HIV transmission when taken by people who did not have the infection. As a result, the government received a patent on this application. However, they have never enforced their patent to collect royalties for its use.

Meanwhile, Gilead Pharmaceutical, the corporation that manufactures this drug, charges up to $2000 a month for this treatment. Since they started manufacturing this medication in 2004, they have collected 36.2 billion dollars in revenue from patients and their insurance companies.

Since the government owns the patent, public health experts are arguing that they can and should enforce the patent to require that Gilead lower the price of the drug (a one month supply of which is estimated to cost $6 to manufacture) to promote more widespread availability and reduce healthcare costs. Alternately, the government could collect royalties from the patent and use that money fund other HIV prevention and treatment efforts.

Either way, the government clearly has leverage to make HIV prevention more accessible and affordable and should absolutely use this power.

Read more here.

Do No Harm: A Doctor’s Case For Single Payer

In 2013, Drs. Ubel, Abernethy, and Zafar published “Full Disclosure — Out-of-Pocket Costs as Side Effects” in the New England Journal of Medicine. In this essay, the authors grapple with the ethical responsibilities of physicians when it comes to the enormous cost of modern medicine. If a surgery or a course of chemotherapy is likely to bankrupt a patient, what is our duty to warn them, to ensure that they have considered both benefits and harms? A larger question, however, was left unasked: “How do we as physicians ethically operate within a medical system that forces people on a regular basis to choose between health and financial stability”

To grasp the extent of the issue, consider that even after the passage and defense of the Affordable Care Act, 27 million American remain uninsured. An additional 41 million Americans are underinsured which is to say that their out-of-pocket expenses (such as deductibles and copays) are enough to cause financial duress, despite having health insurance. And as health insurance deductibles increases faster than wages, the proportion of Americans who are underinsured continues to grow.

The consequences of this are grave. Three out of ten American adults report forgoing needed medical care due to cost concerns. One in four were unable to pay for basic necessities like food, heat, or rent because of medical bills. One third spent down all of their savingsContinue reading “Do No Harm: A Doctor’s Case For Single Payer”

Innovations in Primary Care: Moving Beyond Fee-For-Service

The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.

In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.

Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure.   Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”

Bringing Single Payer to Washington State

Yesterday I attended a meeting of Health Care for All Washington regarding single payer legislation in our state. The particular set of bills they are supporting are SB-5701 and HB-1026 which establish a trust fund (the Washington Health Security Trust or WHST) which would eventually act as a single payer for health care services in the state of Washington.

Specifically, this legislation creates the trust fund, establishes a board of trustees and guidance committees to run the Trust, and then lays out in very broad strokes what the Trust is meant to accomplish. As described in the legislation, the Trust is meant to pay for health care for Washington residents not otherwise covered by Medicaid, Medicare, or private insurance including dental and long term care (think nursing homes). Most likely the funds for the Trust would come from a combination of a payroll tax and a sliding-scale premium.   Continue reading “Bringing Single Payer to Washington State”

Innovations In Primary Care #1: Introduction

As part of my family medicine residency training, I’m taking a month-long elective called Innovations in Primary Care. This month is an opportunity for primary care doctors from family medicine and internal medicine residency programs in Seattle to explore some of the different primary care models being trialed in the Seattle area and to use those experiences to fuel discussion about how primary care (and really, all medical care) can be improved in the United States.

Today was our first meeting, during which we gathered to collectively write an H&P for our current medical system. For those reading this who are not in medicine, the History and Physical or H&P is a semi-standardized note-writing structure that doctors use to describe the subjective and objective information about a patient’s health, assess why  the patient is experiencing illness, and describe the next steps we need to take (diagnostic tests and/or treatments) going forward. It’s a structured way of thinking about a patient that helps us be rigorous and methodical.

It was a gratifying process because each of the doctors at the table shared a passion for making our health care system better, but brought a different set of experiences and priorities to the conversation.

Some of the take-aways I had from this conversation are as follows (in no particular order):

  1. The insurance framework for paying for health care, while originally conceived to improve access to surgical services which would otherwise be prohibitively expensive to most people, was quickly recognized by doctors as a way to extract larger fees for patient care. After all, when a third party (the insurance company) pays the bills, people tolerate much higher fees even if the end result is steady rise in out-of-pocket costs for everyone. Doctors, hospitals, and pharmaceutical companies have abused this system so greedily under the previous usual-and-customary payment system that increasingly rigid cost-containment measures have had to be implemented to control costs. We now live in a society where the average doctor makes $294,000 per year–more than 98.9% of Americans–while medical bills bankrupt patients and health insurance cost suppresses wage growth. Recognizing and holding ourselves accountable to how capitalism in medicine has brought out the worst in us is necessary before we can even begin to conceptualize a new system.
  2. The costs of most important and effective interventions to improve health, including primary care, are recurring and predictable costs that are best paid for through public health funding, NOT through health insurance. Access to clean water, nutritious food, safe housing, and preventive medical care is necessary for All People at All Times.
  3. America fails to invest in public welfare programs because of racism. The idea of the racialized-and-thus-undeserving Other benefiting from public welfare programs (e.g. the racist specter of the Welfare Queen that Reagan so infamously promoted) is fundamentally intolerable to White America. We are comfortable with 1 in 7 people in the United States facing food insecurity if it means we can prevent one person from buying steak with food stamps. There is no justice without racial justice.
  4. Many participants are needed to transform our medical care system into a true health care system. While there are only physicians in this particular group, the real work requires public health professionals, community health workers, housing experts, policy wonks, political activists, artists, chefs, personal trainers, behavioralists, and many others to both design an implement a better system.

I’m looking forward to the experiences and conversations this month will bring, and I hope to walk away with greater insight into how I can be a better advocate for effective and equitable health care in this country.