Health Justice NOW (I) What We Got

Most years around now I was in Washington, DC at the Enrolled Actuaries meeting with one of my evening excursions being a jog to the a bookstore up the road where I could have seen someone like this guy:
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Coincidentally, I found Timothy Faust’s philippic against the US healthcare system in Princeton last month and have been provided the time within which to read it, starting with a section on what we got.

American healthcare means you’re made sick, and then punished for being sick, all so someone else can turn a huge profit. (page 5)

But hospitals had a lot of capacity, hospital beds were going empty, and hospitals were interested in finding ways to fill them – by marketing themselves as the place where a person ought to have their children, for example. These schemes fell short in the face of the Depression, when suddenly nobody could afford healthcare, and hospital beds across the country stayed empty. (page 8)

That hospitals are the primary locus of American health finance discussion is no accident. Much of the momentum that existed for national insurance after World War II was ceded by Harry S. Truman and other powerful Democrats in the face of opposition by industry and racist Southern Democrats. Instead, it was funneled into a bipartisan and industry-friendly movement to massively subsidize the creation of hospitals across the country – the Hill-Burton act of 1946 built hundreds of new hospitals with public money but made no attempt to exert any control over the business of those hospitals – a conscious choice encouraged by the anti-regulatory American Medical Association (AMA) and other anti-national insurance lobbies. Hill-Burton hospitals were thus permitted to use their public funding to offer segregated care or refuse care to the poor. (page 8 footnote)

Teachers, a hospital marketing scheme, WWII, and tax credits: from these components sprawl the massive, ramshackle American health insurance machine. (page 9)

In 2009, 45,000 people died from causes related to uninsurance….they were killed by our health finance model….There were 63 million underinsured adults in 2018, or a third of the adult population. (page 11)

Bitter Pill is a hell of a book because the first two-thirds really dissect several of the structural problems in American insurance, and then the last third has the stupidest conclusion (“Why not just have more private monopolies?”) in print. (page 11 footnote)

These plans are also usually very, very profitable for the insurance companies selling them – up to a 30 percent margin. Of course, these companies like to protect those profits, and often do so by denying care to patients. (page 14)

Does it seem like, maybe, the standard Medicare plans have been hollowed out or made weak so that Part C seems like the most appealing option?…Medicare Advantage – privatized Medicare – represents the government weakening its own insurance programs so it can waste money on paying private companies to do a worse and more expensive job of insuring people. (page 15)

We’re just portable, unstable profit pods, utterly dependent upon the insurer that drains us. (page 32)

There is a school of thought that lays the blame for healthcare costs at the feet of the people who need healthcare. (They seek it “irresponsibly,” we’re told.) This is a callous argument advanced by smart people whose livelihoods depend on them pretending not to know better. *(page 38)

Instead, it may not surprise you to learn that rising costs come from a constellation of American corporations exploiting every loophole and unregulated lever available to them to make as much profit as possible at the expense of patients’ long-term well-being. Often, they do this while receiving hefty subsidies from public money (or while receiving exemptions from paying taxes). Healthcare costs in America are driven up by dozens of actors, each of which acts in ways that increase cost for others, who in turn act in ways that increase costs back at them. It’s a circular firing squad, and nobody involved will change of their own accord. (pages 38-9)

Mylan CEO Heather Bresch saw her salary rise 671 percent to $19 million. And she used that money well: in the 2018 cycle, Mylan executives were among the largest contributors to West Virginia Democratic Senator Joe Manchin. The money stayed in the family: Bresch is Mancin’s daughter. (page 42)

Sometimes, the PBM sets prices such that a patient pays more for a drug through their insurance co-pay than they would if they paid for it out of pocket with no insurance. This is called a “clawback.” On top of that, until it was banned by Congress in October 2018, PBMs would enforce gag orders on pharmacists, forbidding them from telling this to the patient. It was estimated that, before the ban, almost a quarter of all drugs had these clawbacks. (page 47)

The whole output of this big awful machine, this jousting between PBMs and insurers and drug manufactures, is virtually a mass corporate conspiracy to soak Medicare, Medicaid, and you. (page 49)

In short: every year, the American Medical Association advises Medicare’s RVS Update Committee (RUC) about the relative difficulty and cost of different medical procedures. This advice is used to determine how much to pay for each procedure – and since virtually every insurer in the United States bases its payment levels on Medicare’s, the RUC ultimately determines payment levels for every provider in America. The AMA’s advisory team is nominally a representative body for every kind of doctor in the United States: PCPs have a representative, hand surgeons have a representative, cardiologists have a representative, and so on. That sounds good, except that PCPs compose approximately half of America’s doctors. If you’re familiar with America’s electoral college, you might know where this is going. Uh-oh! It turns out that since every specialist has a representative on this body, they prefer to give advice that benefits specialists as a class over PCPs and everyone else. (page 55)

There’s a little truism in health finance known as Roemer’s Law, which posits that any hospital bed that is built will be filled, regardless of need in the surrounding community. (page 57)

With such a dependent customer base, and a government that has at virtually every juncture chosen to enable those who wish us harm, is it any wonder costs are out of control. (page 60)

We have built upon these jagged rocks the loathsome church of American healthcare, in which the question of “Who gets to receive healthcare, and when?”- or, rather, “Whose suffering matters? – is determined by private profitability. (pages 60-61)

Certainly providers do overcharge; hospitals do seek to squeeze as much as they can out of the insurance company. Thus the insurers, who need profit like patients need air and water, have a legitimate and reasonable point. But that their point can only be expressed at the expense of the patient is proof of the moral illegitimacy of the whole industry. (page 63)

How do you square the rampant increase of healthcare costs with the fact that insuring sick people isn’t profitable? Well, if you’re the Democrats, you collaborate with the conservative Heritage Foundation think tank to offer us the Affordable Care Act (ACA), which is, fundamentally, the massive subsidization of the private insurance industry with public money. (page 65)

NFIB v. Sebelius determined that Congress had the power to enact most parts of the ACA, but that it was incapable of mandating that state Medicaid programs had to adopt the new eligibility guidelines. That’s why several states have refused to do so, and why Medicaid eligibility criteria still varies from state to state. It is a barbaric decision and it permits states to refuse desperately needed federal money, to actively harm their people, for reasons of political tribalism. (page 67)

2 responses to this post.

  1. Posted by PS Drone on March 25, 2020 at 1:00 pm

    American ingenuity has been a marvel to the world for at least 150 years. But in recent decades the most successful variations of this is the ability for disciples of American greed to extract $ from activities that should not exist, at the level they do, in the first place. Think trial lawyers, public sector unions, “non-profit” hospitals, most colleges and universities. Little to no recognition or concern for the negative community impacts of their pursuit of greed. Mealy mouth aphorisms like “get the justice you deserve” (and a 30% kicker for me), “let’s not engage in a race to the bottom” (so keep paying your outrageous property taxes), “your life is worth ___ Medicine” (so bankrupt yourself to pay our $7000 per day in-patient fees so that our CEO can continue to enjoy his $4MM compensation), a price tag cannot be put on a valuable post-secondary education (so keep incurring that $100k in student loan debt to keep our administrators flush)….blah blah.

    Our country is morally and ethically lost and we deserve all of the negative financial repercussions that are coming.

    Reply

  2. Posted by Rex the Wonder Dog! 🐶🐶🐶🦴🦴🦴 on March 25, 2020 at 3:42 pm

    Long, Unkept Hippie Hair- Check✔️

    Cool Hippie Headband- Check ✔️

    1970’s “Mutton Chop” sideburns- Check ✔️

    1980’s “Prince Purple Rain” T- Shirt-Check✔️

    What’s NOT to like about Lefty 🙂

    Having approved of Lefty’s work attire, he makes a few, very few, valid points. Just not nearly enough to make his overall position valid.

    Reply

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