Oliver’s Twist

Yesterday, President Barack Obama announced his nomination of Regina Benjamin, M.D., as U.S. Surgeon General. Benjamin founded a rural health clinic in Bayou La Batre, AL, a Gulf coast town of 2,500 people where, according to the Washington Post, 40 percent of the population has no health insurance. “Stories abound,” report Post writers Alexi Mostrous and Michael D. Shear, “of Benjamin making house calls in a muddy Toyota pickup, and accepting buckets of shrimp from patients too poor to pay cash.”

Benjamin said “My father died with diabetes and hypertension. My older brother died at age 44 of HIV-related illness. My mother died of lung cancer because as a young girl she wanted to smoke, just like her twin brother could. My family’s not here with me today, at least not in person, because of preventable diseases. While I can’t change my family’s past, I can be a voice in the movement to improve our nation’s health care and our nation’s health for the future.”

The Surgeon General’s position is a bully pulpit for issuing crucial public health messages. Let’s hope that Dr. Benjamin uses the post to campaign for providing comprehensive health care for rural and minority populations, who lack access to decent health care today. Dr. Benjamin’s appointment, if confirmed by the U.S. Senate, could highlight the issue of health care inequities, which is sorely missing from the current debate on health care reform. What we need is an advocate for minorities and rural folk, not another defender of privatized health care — albeit one who has a moral center. My fear, however, is that President Obama plans are limited only to using her as an “anti-lobby” against those opposed to his so-called health care reforms.

The Wall Street Journal, New York Times, and Washington Post all report today that negotiators for the hospital industry struck a deal with the White House, agreeing to some $155 billion dollars in cuts over the next 10 years. The cuts will come mostly through decreased Medicare and Medicaid payments to hospitals.  The Journal article also reports on a deal in the making with health insurance companies in which that industry agrees to at least $100 billion in cuts over 10 years.

These deals come in the wake of a similar pact between the pharmaceutical industry and the White House for $80 billion in cuts over that same 10-year time period. These supposed savings total to the more than $300 billion in “savings” that President Obama claims will pay for the proposed health care reform package.

These deals are shams. They are supposed acts of “good faith” on the part of the entities that reap profits from health care delivery, demonstrating their acceptance of “shared responsibility” in paying for whatever health care reform package gets cooked up by Obama and the Congress.

I say it’s a sham because they don’t wind up giving up anything! Only individual patients wind up paying. Here’s how this shell game works: Hospitals, drug companies, and the insurance industry agree to $300 billion in “cuts” over 10 years. However, they make it all back through the addition of 40 million newly insured patients. (One of the reasons for the phased-in cuts over 10 years is so that the addition of newly insured patients outstrips the “losses” in Medicare and Medicaid dollars.) The federal government agrees to help subsidize any individual who can’t afford to buy private insurance, and, for those who still can’t afford it, the government-sponsored insurance plan agrees to pay out at a higher rate than Medicare and Medicaid. Hospitals, pharmaceutical companies, and insurance firms make out like bandits.

Patients…well, they don’t do so well. They wind up paying out of their own pockets directly to health care profiteers or indirectly, through taxation, their dollars end up in the coffers of the hospitals, pharmaceuticals, and insurers. The “shared responsibility” isn’t shared at all. The profit-makers in health care are guaranteed a profit, and patients are guaranteed to pay.

This burden will fall heaviest upon those who can least afford it — working people, racial and ethnic minorities, the unemployed, rural populations, and other disadvantaged communities. All the talk about how everyone is pitching in and making a sacrifice is a bunch of hooey aimed at keeping patients quiet when the government and the health care industry puts the screws to them.

The health insurance industry, pharmaceutical companies, and physician job-trusts are spending millions to influence the health care reform package being cobbled together in Washington, D.C. The July 6 Washington Post reports that these groups have hired more than 350 former government staff members and retired members of Congress to lobby key congressional committees and legislators. The Post estimates that the health care industry is spending $1.4 million a day to lobby Congress on the health care reform package. The paper reports that “the Pharmaceutical Research and Manufacturers of America (PhRMA) doubled its spending to nearly $7 million in the first quarter of 2009, followed by Pfizer, with more than $6 million.”

The lobbying effort has had its effect. Clearly the owners of these industries want to minimize their costs in any reform of the health care system while maximizing their access to some 46 million uninsured potentially new customers. The two main health care reform bills being discussed in the Senate’s Finance Committee and the Health, Education, Labor and Pensions Committee both ensure increased access to the uninsured while limiting the costs to the insurance industry — for example, by providing government subsidies to individuals to pay for private insurance.

Minority communities have no real voice in this discussion. The needs of African Americans, Latinos, and other racial and ethnic minorities will be ignored as Congress forges its health care package.

Today’s New York Times reports on a poll it conducted with CBS News on support for government-run health insurance plan — something akin to Medicare for those aged 65 years or younger. The national telephone survey found that 72% of those polled support such a plan. The survey revealed that the majority of people would be willing to pay higher taxes in order to provide health insurance for everyone.

Although the poll did not ask whether people support a single-payer health care system (in which only a government-run health insurance plan would be in effect), it clearly shows widespread support to the idea that the federal government would do a better job running the health care system than private industry. As one poll respondent said in a follow-up interview, “Even though [clinical services] might not be quite as good as what we get now,” he said, “I think the government should run health care. Far too many people are being denied now, and costs would be lower.”

African Americans and Latinos are disproportionately represented in the ranks of the underinsured and uninsured. This fact leads to huge barriers blocking access to needed health care and the resulting health inequities that plague these communities.  A national health insurance plan administered by the federal government, therefore, would help reduce racial and ethnic health disparities.

Atul Gawande, MD

I’m often at odds with Atul Gawande’s views on health care reform in the United States. I’m a staunch supporter of a single-payer, government-run, national health care plan; he supports a market-based system. However, of late, Dr. Gawande has been speaking out in support of the accountable care organization concept pushed by the Dartmouth Institute for Health Policy and Clinical Practice. To the extent that such organizations strive to deliver low-cost, high-quality health care to the communities they serve, Gawande, the Dartmouth Institute, and I are all on the same page. (I go further and say that we need such organization on a national scale. All health care providers would be organized into such teams in a national health care plan, rather than voluntarily doing it as smaller, market-based units.)

In his recent New Yorker magazine article, Dr. Gawande tells a vivid and moving story about the reasons for the high cost of medical care by focusing on McAllen, Texas, which is a border town with one of the most expensive health care markets in United States. It’s a must-read article.

I also think you should read Maggie Mahar’s June 12th post in her blog, Health Beat. In this posting, she prints excerpts from Dr. Gawande’s address to the graduating class at the University of Chicago’s Pritzker School of Medicine. Evidence-based practice, which we emphasize in the training of our family medicine residents here at UVa, results in high-quality, low-cost care. I also believe it leads to more equal care because it mitigates the influence of implicit racial bias and stereotyping.

AP Photo/Mary Ann Chastain

President Obama told the delegates and other attendees today at the annual meeting of the American Medical Association that he supports a market-based national health plan in which the federal government offers an insurance plan that competes with private insurers. As he said earlier in the week in a speech in Green Bay, Wisconsin, Obama feels a government-run insurance option is necessary “because if the private insurance companies have to compete with a public option, it will keep them honest and help keep prices down.”

Such a plan — predicated on defending the profits of the insurance industry — will fail to provide high-quality health care to all, and it will do little to reduce or eliminate racial and ethnic health disparities. The profit interests of the insurance industry will continue to drive what services are provided and to whom, rather than the health needs of the insured. At best, a government insurance plan that is just one among many insurers in an insurance-exchange market will act only to force a de facto cap on profits.

Instead, we need a government-run, single-payer health plan that distributes funding based on the health needs of the population. Because the funding would derive from a single source, administrative costs would be vastly reduced. A single-payer could demand medications at cost and enforce provision of proven therapies and interventions, thus helping to ensure provision of high-quality care to all. In such a manner, racial and ethnic health inequities would be reduced.

Health care is a public good, a human right to be shared by all — not a commodity to be sold at a profit.

That’s my two cents on President Obama’s AMA speech. What do you think?

Today’s Washington Post reports that 30 key lawmakers involved in drafting legislation for planned health care reform have financial holdings in the industry that may total as much as $27 million. This fact is not the only reason the U.S. Congress is likely to pass health-care legislation throwing billions to the insurance industry.

Democratic and Republican Party politicians — to a person — are wedded to a system where industries, including the health care industry, are based on making profits. Both the bill being discussed in the Senate’s Health, Education, Labor and Pensions Committee (chaired by Senator Edward Kennedy) and the Senate’s Finance Committee (chaired by Senator Max Baucus) propose mandating all individuals have insurance coverage. Each bill proposes ways the federal government can provide resources to individuals to pay for this insurance coverage. A topic of hot debate in the U.S. Congress is how the federal government will finance these plans. Employers will be hit to finance workers’ insurance, although many businesses will receive credits from the feds to soften the blow. Workers may have their benefits taxed, as well.

However, the bottom line is that more money and increased profits will be funneled to the robber barons of the insurance industry, as they stand to gain some 47 million new customers. Isn’t some kind of health insurance coverage better than no coverage at all? I think we need to fight for what we want rather than accepting whatever it is we get. We want and need universal health insurance and a single-payer system.

Access to health care is an important first step toward eliminating racial and ethnic health inequities; nevertheless, it’s not the complete solution. As I noted in an earlier post, health inequities are a reflection of deeper social inequities. Until these social inequities are addressed, we still will remain plagued by health disparities.

Nancy Sebelius, Secretary of the U.S. Department of Health & Human Services, released a report today highlighting the health care disparities suffered by low-income and minority populations in the United States. As has been noted in multiple studies, these populations have higher rates of obesity, diabetes, some cancers, and HIV/AIDS. The Sebelius report notes the reduced access to health care that low-income and minority populations face, owing to low rates of insurance coverage, lack of primary-care providers for this population, and a lack of having a usual source of care. Minority populations and low-income workers receive significantly less routine or preventive care than do whites in this country.

The DHHS Secretary argues that these disparities underscore the need for health care reform. She is correct in claiming that “meaningful reform must invest in prevention and wellness and ensure that all Americans have access to high-quality, affordable care.” Truly universal health insurance would go a long way toward reducing racial, ethnic, and social-class disparities in health.

However, current proposals for health care reform fall well short of providing such universal coverage. The draft health care reform bill released by Senator Edward Kennedy yesterday, for example, will, if enacted, line the coffers of the U.S. insurance industry while doing little to improve the health of minorities and other working people

Kennedy, the Chairman of the Senate’s Health, Education, Labor, and Pensions (HELP) Committee, proposes an “Affordable Health Benefits Gateway,” which would be a clearinghouse to connect individuals and employers with insurers. Under the Kennedy plan, all individuals would be mandated to purchase insurance. Since the plan mandates that employers (with some exemptions) provide insurance or pay employees to buy insurance elsewhere, insurance companies stand to gain billions in new revenue. To sweeten the pot for the insurance barons, the Kennedy bill would authorize credits to help eligible businesses buy insurance for their employees.

The HELP bill would create a government-sponsored insurance program that would compete alongside the private insurers in the “Gateway.” However, this half-stepping approach does not challenge — in fact, it supports — the right of the insurance companies and health care industry to make profits off the pain and suffering of working people.

Health care is a right, not a privilege. Hospitals and other providers of health care services should be driven not by making a profit, but by providing services known to improve the health of the populations we serve. We need a national health program run by the federal government — much like the Veterans’ Administration Health System but covering everyone in the United States.

The 17th Century poet John Milton once said that “The childhood shows the man, as morning shows the day.” The current issue of the Journal of the American Medical Association (JAMA) carries a report that finds that childhood shows the adult disease.

McEwen et al(1) explain that the negative childhood experiences of working-class youth and other disadvantaged people lead to adult disease. “Adverse childhood experience,” they note, “is one of the largest contributors to such chronic health problems as diabetes and obesity, psychiatric disorders, drug abuse — almost every major public health challenge we face.”

The authors discuss how the “toxic” stress of poverty, physical and emotional abuse, chronic neglect, and violence disrupts brain architecture and other organ systems, increasing the risk of chronic illnesses in adulthood. The endemic extreme poverty of the African-American community; the structural and institutionalized physical and emotional abuse of racial discrimination; the chronic neglect of African-American communities by city, state, and federal governments; and the rampant violence afflicting our communities all leave deep wounds in African-American youth. These wounds fester over the years, becoming manifest in the huge inequities in disease incidence and mortality that plague African Americans. Other oppressed groups face similar problems: Latinos, Asian-Americans, and women to name a few.

There is hope, however. As individual groups of disadvantaged peoples, we are “minorities.” However, together we are the majority. We need to band together and demand that the social inequities that underlie our ill health be eliminated. As I will continue to argue in this blog, eliminating social inequity will do far more to eliminate health inequities than any campaign aimed at individual health behaviors or physician practices.

1. Shonkoff JP, Boyce WT, McEwen BS. Neuroscience, Molecular Biology, and the Childhood Roots of Health Disparities: Building a New Framework for Health Promotion and Disease Prevention. JAMA 2009;301:2252-59.

On Saturday, May 30, The New York Times reported on a joint statement released by Massachusetts Senator Edward Kennedy and Montana Senator Max Baucus, saying they would work together to find “common ground on health reform legislation.” In their statement, Kennedy, the chair of the Senate’s Committee on Health, Education, Labor, and Pensions, and Baucus, the chair of the Senate’s Finance Committee, claimed that “reforming the nation’s health care system to cut cost, improve quality and provide affordable coverage remains the top priority on our two committees.”

However, neither Kennedy nor Baucus propose to do the one thing that would accomplish these aims: establish a single-payer health care system. The evidence clearly shows that single-payer systems control health care costs. Every other major capitalist country in the world provides all of its citizens with health care coverage and has some systematic nationwide strategy to keep costs under control. As a result, these countries spend, on average, about half what the United States spends on health care.

And their health is better! The United States has the highest rate of preventable deaths before the age of 75 among rich, industrialized countries. If the United States had the same rate of preventable deaths as the three countries with the lowest rates, more than 100,000 deaths would be prevented each year.

In 2007, a consulting team from McKinsey & Company reported on their analysis of U.S. health spending. They found that the United States spent some $500 billion a year more than would be expected just based on its per capita income. Moreover, this huge discrepancy could not be explained by the poorer health of U.S. citizens. Rather, the difference was the result of higher drug costs, higher profits, and taxes due to a reliance on for-profit health care providers and insurers and higher administrative costs.(1)

The problem of high health care costs boils down to the greed for profits. Let’s take profits out of the picture. Establish a government-run, national health program that runs at cost. Health care is a human right, and it should be provided to all.

1. Accounting for the cost of health care in the United States. McKinsey Global Institute. January 2007.