Sunday, April 25, 2021

035 The Erickson Report for April 8 to 21, Page One: A Longer Look at Healthcare

035 The Erickson Report for April 8 to 21, Page One: A Longer Look at Healthcare

We start with another instance of our occasional feature, A Longer Look, where we go into something in somewhat more detail than usual. In this case, it's A Longer Look at healthcare.

The experience of covid has generated warnings among health experts that we as a nation are no more prepared for the inevitable next pandemic than we were for this one. Those folks are usually thinking in terms of stockpiles of medications and other equipment and distribution mechanisms for them in times of need along with better tracking once some new virus crops up to contain any outbreak as much as possible.

But there's another issue, less often discussed but at least as important: The experience of Covid has laid bare the fact that the very nature of our health care system is broken and needs overhaul, need whole-scale restructuring. The failures, delays, wildly varying responses, erratic and fragmented treatment efforts, and gross inefficiencies that together cost tens if not hundreds of thousands of lives over the past year are a direct outcome of that fractured system, an outcome that has not revealed but rather has put an exclamation point to the fact that we do not have a health care system, with a goal of maximizing health, but a health care industry, with a goal of maximizing profit.

In the words of Bonnie Castillo, RN, executive director of the National Nurses United union, "The pandemic has highlighted in deadly detail what nurses have known for decades: Our current health care system is a colossal failure and leaves far too many of our patients to suffer and die unnecessarily.'

How bad was that failure? A new report released March 16 by Public Citizen argues that the nation's coronavirus response was hindered "at every turn," adding that "The reality is that our for-profit healthcare system put the U.S. at a dangerous disadvantage and hindered rapid response." That resulted, the report found, in millions of Covid-19 infections and hundreds of thousands of deaths that could have been prevented - deaths, it must be noted, that disproportionately fell on communities of color, with people dying at 3-5 times the rates of whites, a direct result of the unequal access to care that is another effect of our corporate-dominated, profit-driven system.

The root of the problem is that our access to health care, available on a fee-for-service basis, is mediated through insurance. While Medicaid and Medicare and some other government programs do provide insurance, the way the majority of adults in the US get health insurance for themselves and their families is through their employer. That is, our access to health care is based on private, profit-seeking insurance tied to our employment. Suddenly have tens of millions unemployed - as during, for example, a COVID pandemic - and you just as suddenly have tens of millions uninsured, unable to pay for health care costs that can be crushing if you get even a little sick and difficult to cover even for routine care even if you don't. And that leads of large numbers of preventable deaths.

The Public Citizen white paper built off a study, released March 4, from FamilesUSA, which concluded that over 40% of US Covid-19 infections and about 1/3 of the deaths have been associated with lack of health insurance - so by February 1, it found, nearly 11 million COVID-19 infections and over 140,000 deaths were potentially connected to gaps in having health insurance.

And even having health insurance may not be enough. The number of underinsured Americans, those who have some sort of health insurance but effectively can't use it because the co-pays and deductibles are too high, leading to delayed or avoided care, that number is stunningly high: a quarter to nearly 30% of all adults.

As a result of the Affordable Care Act, most particularly through expansion of Medicaid, about 20 million non-elderly Americans got insurance - but the combined total of uninsured and underinsured working-age adults remained stuck at about 45% of that working-age population, around 87 million people, because even as the number of uninsured dropped, the number of underinsured rose.

So we are now at the point where according to a poll by Gallup and West Health, released March 31, nearly one in five US adults, nearly 50 million people, say they could not afford quality healthcare if the need arose and the same number say that someone in their household has foregone care in the past year because of the cost, with more than a third of those in low-income households reporting having done that, a finding confirmed by a GoHealth survey from November which found that 1/3 of people below 65, the eligibility age for Medicare, are planning to reduce preventive care appointments and/or everyday household purchases in order to afford health insurance - all while more than 8 million Americans have started a crowdfunding campaign in a desperate and usually failing attempt to raise money to pay for medical care. That is after 10 years of the Affordable Care Act, the thing that was supposed to solve the problem of access to health care.

So if you want to say the ACA is better than what we had before, go ahead - so long as you remember that that's only by comparison and "better than we had" is a damn low bar to get over. It's not nearly good enough. Even though the US spends more on health care than any other OECD country - the OECD being the Organization for Economic Cooperation and Development, it's essentially the industrialized nations of the world - life expectancy here has decreased in recent years. Not that it was good before: According to the WHO, the US ranks 40th among nations in that regard. And even as life expectancy has declined, costs for consumers have continue to rise. According to a survey by the Kaiser Family Foundation, annual premiums for employer-sponsored family heath coverage rose 55% in the first eight years of the ACA.

And the ACA's utter failure to challenge or impact that employer-provided corporate insurance model, a model it left untouched, in fact endorsed as the subsidies on the exchanges amount to public financing of private profit, that failure meant that by its very nature the ACA could not deal with the pandemic's surge in required care. And people - lots of people - died as a result.

What's the alternative? What could have helped now and would help in the future? You already know the answer: Take the profit out of health care. And the biggest step we can take in that direction now is what's known as single-payer health coverage, popularly known these days as Medicare for All.

On March 17, Reps. Pramila Jayapal and Debbie Dingell introduced the Medicare for All Act of 2021 with the support of 300 local, state, and national organizations - along with over half of the Democrats in the House of Representatives.

It envisions a two-year transition to a Medicare for All system that would also expand what Medicare now offers to include dental, vision, reproductive health, mental health, long-term care, and other services with no out-of-pocket costs attached. No deductibles, no co-pays. No private insurance premiums. And fewer hassles finding a health care provider because there are no in- or out-of-network issues.

Polls consistently show a heavy majority of Americans, even nearly half of GOPpers, favor a single-payer system, with overall support running from the upper 50s to the upper 60s depending on exactly how it's described.

Despite that, the chances of this bill passing are actually slim, and we'll get to some reasons why later, but it's still a good thing first because it lays down a marker and provides leverage, leverage which Bernie Sanders is already using in the Senate to push for amendments to the next reconciliation bill that would reduce the eligibility age for Medicare from 65 to 60 and revoke the ban on Medicare negotiating drug prices with manufacturers.

According to an analysis last April by the healthcare consulting firm Avalere, lowering the eligibility age to 60 could extend the program's coverage to as many as 23 million more people.

One important feature of a single-payer system is that it is both more efficient and simpler for consumers to navigate. There is a tremendous amount of administrative cost and waste in our current chaotic, profit-driven mess, with multiple insurance corporations negotiating with multiple providers using multiple sets of standards and levels of eligibility and multiple billing systems - all of which complications disappear with single payer.

That is a big part of the reason why studies have repeatedly shown that a single-payer system costs less than we pay now.

For example, in January of 2020, a team of analysts at three University of California campuses examined 22 studies on the projected cost impact of single-payer health insurance and found that every one of them, even one from the right-wing Mercatus Center, predicted that it would yield net savings over several years. The size of the savings varied with the assumptions made, including the exact nature of the program - but every one said it would mean providing comprehensive coverage to everyone while costing less.

And there were more to come. In February 2020, an analysis done at Yale and published in the peer-reviewed medical journal Lancet found that a single-payer system could slash the nation’s health-care expenditures by 13 percent, or more than $450 billion, a year, while saving about 69,000 lives.

In December 2020, the Congressional Budget Office released its estimate of the cost of implementing a single-payer program. The CBO considered four different single-payer designs and found that such a system would save somewhere between $42 and $743 billion in 2030 alone.

The CBO option that most closely approximates current Medicare for All proposals shows savings of around $650 billion a year by 2030. Even adding long-term support and services to that still shows savings of $300 billion a year.

One significant finding was that administrative costs for Medicare - already just 2%, so low that during the debate on the ACA, the insurance industry whined that it was unfair competition - would be even lower under a single-payer system, about 1.5 to 1.8 percent.

And in a paper published January 5 of this year, a team from Cambridge Health Alliance/Harvard Medical School and the University of California San Francisco looked at the relationship between universal healthcare and the use of medical services. They considered the claim that universal access to care would result in so many people using so much care that the system would be overwhelmed by user costs, swamping any administrative savings and making Medicare for All just to damn expensive - and they found the claim to be utterly false.

Between 1973 and 2020, various models projected utilization increases, that is, the increase in demand for medical services, up to more than 21% - but this team looked at the actual history of past coverage expansions in the US and 10 other affluent countries, and found that the changes in fact were modest and that nearly all previous predictions overestimated the impact.

According to the authors' review of the historical record, universal coverage would increase ambulatory visits by no more than 10% and hospital use by no more than 3%, with "modest administrative savings" offseting the costs of increases.

So what all this comes down to is that a single-payer system provides excellent health care, a wider range of services, is easier for consumers to navigate, costs less, and has the support of a majority of the population.

Which it is why it is so incredibly frustrating and disappointing, even depressing  - but I have to add not surprising - to note that the hierarchy of the Democratic Party, including Nancy Pelosi in the House, Chuck Schumer in the Senate, and Joe Blahden in the White House are all against it.

Pelosi is actively discouraging House Democrats from supporting Medicare for All; Schumer says Senate democrats will go with "what gets the most votes," which by definition in a divided Senate means either nothing or what's pleasing to the reactionaries in the body; and as for Bladen, he said in May 2020 that as president he would veto Medicare For All legislation.

In fairness, I'll note that he supports lowering the Medicare eligibility age to 60 - but in truth I'll add that happened only after it became obvious that healthcare was a significant enough issue in the campaign that he had to find a way to soften his outright rejection of Medicare for All.

Anyway, what this triumverate of political turpitude, this trio of twits, wants instead of a single-payer plan is some minor tweaking of the ACA, the very thing that has had 10 years to prove itself and has instead demonstrated it is not up to the task of either universal coverage, cost containment, or emergency response.

Their central idea is to create a government-backed “public option” health plan and expand Obamacare subsidies - subsidies which, again, amount to public financing of private profit.

And as for the public option, have we really forgotten that such a thing was supposed to be part of the original ACA? Is that truly the best the Democratic hierarchy can offer us? A promise to re-fight the battles of 10 years ago? With the promise that this would, in the words of Sen. Michael Bennet, a co-sponsor of a bill to enact Blahden's vision, "finish the work of Obamacare?" A plan that would leave intact, indeed embrace, the very fractured, fragmented, profit-driven, corporate-dominated healthcare network that has been such a disastrous failure, particularly over this last year?

Is that really the best they can offer?

And why? Why are they shying away from Medicare for All? Are they acting out of a timid fear of what the right-wing will say about the party's candidates in 2012? I know Nancy Pelosi is. Are they too tied to corporate interests? I know Chuck Schumer is. Are they thinking that Medicare for All is a slap in the face to their legacy? I know Joe Blahden is. Or are they just stubbornly unwilling to admit they got it wrong?

But why isn't really the point, first because all that is true of all of them and second because it doesn't make a damn bit of difference why. What matters is the lives and the health that will be lost as they repeat the blunders of 10 years ago.

Ten years ago, the Obama White House didn't start on the ACA with a demand for what should be done, expecting to have to negotiate back from there but winding up with the maximum that could get passed at the time. Instead, they started with a call for what they thought would pass, with the obvious and predictable result that they wound up with clearly less than that.

When during the bargaining over the ACA, I complained about that approach, I was told "Don't worry, we'll get this through and next year we'll come back and make is stronger." And I called it: I said "No you wont; you'll spend your time and energy trying to defend against losing what you've got."

As Yogi said, It's deja vu all over again as the Democratic leadership resuscitates proposals from a decade past and says with that and a couple of tweaks and jiggles, we will "finish the work of Obamacare." And they will happily clap each other on the back and talk of the great work they have wrought - while tens of millions continue to suffer its failures.

I suppose I could call it an outrage - but the truth is it feels much more like a tragedy.

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