Category Archives: Medicaid

Single Payer A Bargain

Another shout out to Don McCanne for the following.

On Friday, the Nation published an article by Steffie Woolhandler, David Himmelstein, and Adam Gaffney.

You may recall these folks from my book review, “Health Care Under the Knife,” and it’s conclusion, “Some Final Thoughts on ‘Health Care Under the Knife.'”

Rather than regurgitate it for you, I am letting you read it in its entirety. But before I do, let me bring to your attention, an issue that is flying under the radar and has serious consequences for the country, our rights, and for the future of health care and other social programs.

Those lovable brothers from the Midwest, Charles and David Koch, are funding a group called ALEC, the American Legislative Exchange Council. One of the goals of ALEC is to call an Article V (of the Constitution, for those of you not familiar with the document) that allows for the creation of a convention in the event the government gets too much power.

I recommend you read up on it because it will radically alter our system of government for the benefit of the corporations and wealthy. Say goodbye to Social Security, Medicare, Medicaid, and direct election of Senators, to name a few goals.

That brings me to a quote I must let you read from a man who has no clue what he is talking about, and is emblematic of the dysfunction of his party. That man is former Oklahoma Sen. Tom Coburn, himself a physician who said the following regarding a convention and why he and others feel it is necessary.

“We’re in a battle for the future of our country…We’re either going to become a socialist, Marxist country like western Europe, or we’re going to be free. As far as me and my family and my guns, I’m going to be free.”

In case you missed that, let me repeat it:

“We’re in a battle for the future of our country…We’re either going to become a socialist, Marxist country like western Europe, or we’re going to be free. As far as me and my family and my guns, I’m going to be free.” Violent, ain’t he?

Pray tell, what country in western Europe is Marxist? Last I heard, none. Folks, these guys not only want to take away health care, they are still fighting the Cold War and godless, Marxist Communism.  No, what they are really about is defending a system, both economic and health care-wise, that cannot be sustained.

Here is the article in full:

Last week, Charles Blahous at the Koch-funded Mercatus Center at George Mason University published a study suggesting that Bernie Sanders’s single-payer health-care plan would break the bank. But almost immediately, various observers—including Sanders himself—noted that according to Blahous’s own estimates, single payer would actually save Americans more than $2 trillion over a decade. Blahous doubled down on his argument in The Wall Street Journal, and on Tuesday, The Washington Post’s fact-checker accused Democrats of seizing “on one cherry-picked fact” in Blahous’s report to make it seem like a bargain.
The Post is wrong to call this a “cherry-picked fact”—it’s a central finding of the analysis—but it is probably right that single-payer supporters shouldn’t make too much of Blahous’s findings. After all, his analysis is riddled with errors that actually inflate the cost of single payer for taxpayers.
First, Blahous grossly underestimates the main source of savings from single payer: administrative efficiency. Health economist Austin Frakt aptly demonstrated the “bewildering complexity of health care financing in the United States” in The New York Times last month, citing evidence that billing costs primary-care doctors $100,000 apiece and consumes 25 percent of emergency-room revenues; that billing and administration accounts for one-quarter of US hospital expenditures, twice the level in single-payer nations; and that nearly one-third of all US health spending is eaten up by bureaucracy.
Overall, as two of us documented recently in the Annals of Internal Medicine, a single-payer system could cut administration by $500 billion annually, and redirect that money to care. Blahous, in contrast, credits single payer with a measly fraction of that—or $70 billion—in administrative savings.
Our profit-driven multi-payer system is the source for this outlandish administrative sprawl. Doctors and hospitals have to negotiate contracts and fight over bills with hundreds of insurance plans with differing payment rates, rules, and requirements. Simplifying the payment system would free up far more money than Blahous estimates to expand and improve coverage.
Next, Blahous lowballs the potential for savings on prescription drugs. He assumes that a single-payer system couldn’t use its negotiating clout to push down drug prices, ignoring the fact that European nations and the US Veterans Affairs system achieve roughly 50 percent discounts relative to the US private sector. (Single payer’s only drug savings, he argues, will come from shifting 15 percent of brand-name prescriptions to generics.) Hence Blahous foresees only $61 billion in drug savings in 2022, even though tough price negotiations would likely achieve threefold higher savings.
Third, Blahous underestimates how much the government is already spending on health care. For instance, he omits the $724 billion that federal agencies are expected to pay for employees’ health benefits over the 10 years covered by his analysis, which would simply be redirected to Medicare for All. He also leaves out the massive savings to state and local governments, which would save nearly $3.6 trillion on employee benefits and another $5.3 trillion on Medicaid and other health programs. Hence, much of the “new money” needed to fund Sanders’s reform is already being collected as taxes.
Yes, there will need to be some new taxes—albeit much less than Blahous estimates. But those new taxes would just replace—not add to—current spending on premiums, co-pays, and deductibles. Additionally, at least some of the new taxes would be virtually invisible. For instance, the $10 trillion that employers would otherwise pay for premiums could instead be collected as payroll taxes. Similarly, Medicare for All would relieve households of the $7.7 trillion they’d pay for premiums and $6.3 trillion in out-of-pocket costs under the current system.
It’s easy to get lost in the weeds here. But at the end of the day, even according to Blahous’s errant projections, Medicare for All would save the average American about $6,000 over a decade. Single payer, in other words, shifts how we pay for health care, but it doesn’t actually increase overall costs—even while providing first-dollar comprehensive coverage to everyone in the nation. The Post’s fact-checker is wrong: Single-payer supporters can and should trumpet this important fact.
Of course, the most important benefits of single payer are altogether invisible in economic analyses like the one performed by Blahous. No matter what injury or illness we faced, we would be forever freed from one great worry: the cost of our care. It’s hard to put a price tag on that kind of freedom. Yet, paradoxically, even the slanted analysis of a libertarian economist provides evidence that it would be fiscally responsible.
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Medicaid Work Requirements Worsen Health

Back in May, I posted a link to a Health Affairs blog article, Social Determinants Of Health: A Public Health Concept In Conflict in which it was reported that the current regime was seeking to impose work requirements for people on Medicaid.

As reported then, and on Monday in a follow-up article, CMS approved the first waiver to implement a work requirement for Medicaid beneficiaries in Kentucky on January 12th.

The article stated that a couple of weeks ago, a district court found the approval of these work requirements to be “arbitrary and capricious”, and in direct violation of the Administrative Procedures Act of 1996.

According to the article, CMS failed to consider whether the waiver’s estimated removal of 95,000 Kentuckians was in line with the program’s goals of furnishing medical assistance, and the judge ordered the waiver to be returned to CMS.

It was the government’s argument, the article states, that new research into the social determinants of health demonstrate that income and employment are associated with improved health, and so a work requirement thereby fits within the goals of the program.

The case in Kentucky hinged on the fact that work requirements worsened financial assistance, which the judge pointed out is a main tenet of the program.

The author then writes that if CMS wants to use research within the social determinants of health, then he will analyze Medicaid work requirements through this lens. A recent post in Health Affairs focused on the perversion of social determinants of health as a concept, and the current post builds off that one, to demonstrate that this regime’s justification for Medicaid work requirements is misguided at best.

To illustrate this, he follows a theoretical low-income worker, a 50-year-old from Louisville, who could no longer work in his job as a longshoreman due to cardiovascular disease and suffered chest pain whenever he exerted himself. He is uninsured, has a wife and three adult children. And is also trying to find a job.

The author continues by examining the following issues: Unemployment and Health, Medicaid Improves Health, Medicaid Work Requirements Harm Those With Jobs, and concludes by stating that Medicaid Work Requirements Worsen Health.

The theoretical case of the 50-year-old longshoreman is not so theoretical, as each of the 16 Kentucky plaintiffs in the case demonstrated. One is a graduating student with endometriosis, another is a mother of four with congenital hip dysplasia, and another is a partly blind mortician (no jokes, please) with chronic lung disease. All would have risked losing their coverage as a result of work requirements.

And to make the case more clearly, your humble blogger, while not currently on Medicaid, but eventually will be, has end-stage renal disease, and does peritoneal dialysis every night at home, and goes to the clinic twice a month for blood work and to see the nephrologist. In addition, every two weeks on a Monday, as will happen this coming Monday, I have to be home to receive my supplies, and this Friday must call in another order. Working a full-time job, if one were available that matched my experience, would prevent me from doing so.

This is another reason why our health care system is broken and needs to be replaced by a single payer system that does not separate out older beneficiaries, as Medicare does, poorer ones as Medicaid does, and children and military personnel, as the other programs do.

One system for all Americans.

Health Care, Immigration, and the Supreme Court

This week America underwent a shock of such magnitude that many believe that this is the end of the experiment begun in 1776, and the United States lost its standing as the “Shining City on a Hill.”

We have witnessed the cruelty of the Trump regime towards innocent children snatched from the arms of their parents, simply because their parents want to escape the violence and oppression of the drug gangs rampant in their home countries.

These parents want not only to secure for their children a life free from being recruited into these gangs, they also want to provide their children with a better life.

And most of them did so according to US immigration law. They presented themselves at legitimate border crossings, and were summarily arrested, had their children separated from them, the children, some as young as a few months old, put in cages, or transferred across the country, and placed in facilities where no press or Congressional observers are allowed to see for themselves, except on special guided tours where they cannot speak to the children.
Recently, a judge in California ordered the regime to re-unite the children with their parents and effectively ended the zero-tolerance policy.

Tomorrow, at 11 am, I, and many others around the nation will take part in a march to protest this cruel and un-American action. The march I will be attending will be held in West Palm Beach and will cross the Intracoastal Waterway by way of a bridge connecting the mainland with Palm Beach island. The march will terminate at Mar-a-Lago, the former home of Marjorie Merriweather Post, heiress to the Post cereal fortune, and that is now owned by the Orangutan.

Why am I writing this, and what does it have to do with health care? And what does the Supreme Court have to do with these other issues?

That is what this post will attempt to address.

To begin with, the immigration issue will have a profound effect on the health care system, as the older Americans get, the more home health and nurses’ aides they are going to need.

Preventing these unfortunate men, women and children, fleeing violence and drug gangs, and civil war and corruption at home, will mean that in the future there will be fewer workers to take these and many other jobs in health care and other industries.

In addition, the so-called “travel ban”, is really a cynical attempt to impose a Muslim ban without calling it one. The Supreme Court weighed in on this move this week, ignoring the racist comments made by the Orangutan, and gave him wide latitude to ban anyone he does not like.

This will have the chilling effect of preventing both medical students and physicians from coming to the US, not only from the countries on the list, but all other Muslim nations. The medical travel industry, also may feel some effect, as providers and facilitators from Gulf states, and other nations in the region, may be prevented from attending conferences and speaking engagements, and Americans who go to the UAE may be given greater scrutiny upon return to the US.

As a grandson of immigrants, this un-constitutional, un-American, and inhumane action by this regime is very disturbing and sickened me when I heard the cries of those children. But, according to recent polling on the issue, 58% of Republicans approved of the separation of children from their parents, while 92% of Democrats disapproved. The CNN poll results are here:

On top of the immigration debacle, and the “travel ban”, there was a third and more devastating blow to American democracy and to the Republic this week. The retirement of Justice Anthony Kennedy, a swing vote on many issues brought before the Court, portends that the Court will be radically altered once a replacement is chosen and confirmed by the Senate.

But unlike the Merritt Garland nomination, Mitch McConnell is vowing to confirm whatever nominee the Orangutan appoints, and the regime promises to appoint a strict Conservative justice. Several commentators have indicated that abortion, LGBTQ rights, and maybe even health care, could be overturned if one more current justice, most probably Ruth Bader Ginsberg, retires or like Scalia, dies in the next two years. She is 85.

Overturning Roe v. Wade and making abortion illegal once again, will force women to seek back alley abortions, and will severely impact their health and lives. Also, it is possible that birth control and access to it, may be denied to women, and that will have serious impacts on health care in the future. Some believe that Roe is settled law, but don’t count on them being right. The Religious Right is waiting for the day that women are forced to carry to term pregnancies they don’t want, and then have any neo-natal or post-natal care taken away, so that they and their babies suffer needlessly.

A strict Conservative on the bench also threatens gay marriage and LGBTQ rights, as it was Justice Kennedy who broke with the Conservatives and said that gay people had a constitutional right to marry. It may mean that more cases like the recent Colorado case may be decided in the plaintiff’s favor, albeit without the bias the state Commission showed to religion.

Lastly, health care could face enormous challenges ahead if the makeup of the Court swings radically to the right. The current Court ruled that the ACA was Constitutional, but since the coup of 2016, the GOP has steadily destroyed the law and a radical Supreme Court just might put the last nail in the coffin and deny millions of Americans health care. There is also a health care bill in Congress that will remove many diseases and pre-existing conditions from coverage.

This is especially disturbing to yours truly, as I have one of those pre-existing conditions: ESRD. Right now, I have Medicare only, but who knows what a radical Court may do to that and the other health care programs such as Medicaid, CHIP, etc.

In college, I was taught that the Court generally swings from liberal to conservative, but in my lifetime, it has gone from liberal to conservative, to radically conservative, so that now we may be headed for a judicial, corporate dictatorship where the people have little or no rights, and Corporate and religious interests have all the rights.

The following quote sums up our predicament:

“When fascism comes to America it will be wrapped in the flag and carrying a cross.”
Sinclair Lewis

So, what do we do?

Well, the march tomorrow morning is a start. I have been critical of those groups opposed to this regime sitting on their kiesters and doing nothing except marching once a year in January for two straight years in the Women’s Marches. This crisis is bigger than just one demographic group. This fight is for the soul of the nation and for the Republic as a democratic republic. A journalist heard this morning on MSNBC said she went to Minnesota recently when the Orangutan was there, and she said that the cab driver told her that he is a Republican, is against the Orangutan, and cannot speak to friends about him because they believe him 100% and think he is a god.

Great! Now we have a Caucasian version of Kim Jong Un.

We have to work together, because in the words of Pastor Niemoeller:

First, they came for the Socialists, and I did not speak out—
Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out—
Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out—
Because I was not a Jew.
Then they came for me—and there was no one left to speak for me.

The Founding Fathers knew something like this would happen, but never thought that the Electoral College, created to prevent this, would actually make it a reality. We are living in scary times.

Have a good weekend everyone, and if I don’t write before Wednesday, have a safe and happy Fourth…it may be our last.

Social Determinants Of Health: A Public Health Concept In Conflict

Source: Social Determinants Of Health: A Public Health Concept In Conflict

Obamacare: The Last Stage of Neoliberal Health Reform

In my recent review of the Introduction to Health Care under the Knife, the term “neoliberalism” was discussed as one of the themes the authors explored in diagnosing the root causes of the failure of the American health care system.

For review, the term neoliberalism refers to a modern politico-economic theory favoring free trade, privatization, minimal government intervention in business, reduced public expenditure on social services, etc. (Source: Collins English Dictionary – Complete and Unabridged, 12th Edition 2014)

As defined in Wikipedia, and as I wrote in my review, neoliberalism refers primarily to the 20th-century resurgence of 19th-century ideas associated with laissez-faire economic liberalism. Those ideas include economic liberalization policies such as privatization, austerity, deregulation, free trade and reductions in government spending in order to increase the role of the private sector in the economy and society. These market-based ideas and the policies they inspired constitute a paradigm shift away from the post-war Keynesian consensus which lasted from 1945 to 1980.

This recrudescence or resurgence gained momentum with the election of Ronald Reagan to the presidency, and with the Republican takeover of the House of Representatives in the 1994 midterm election, which made Newt Gingrich Speaker of the House, and implemented the Contract with America. (I’ve called it the Contract on America, for obvious reasons)

Yet, the full impact of neoliberalism was not felt until the rise of the TEA Party in the run-up to the passage of the Affordable Care Act, or Obamacare, and that led to the Freedom Caucus in the House that has tried unsuccessfully multiple times to repeal and replace Obamacare with basically nothing.

Economist Said E. Dawlabani, in his book, MEMEnomics, describes the period from 1932 to 1980, which includes the post-war Keynesian consensus, as the second MEMEnomic cycle, or “Patriotic Prosperity” MEME. The current period, from 1980 to the present, represents the third MEMEnomic cycle, or the “Only Money Matters” MEME.

It is in this period that the American health care system underwent a radical transformation from what some used to call a “calling profession” to a full-fledged capitalist enterprise no different from any other industry. This recrudescence of 19th century economic policies did not spring forth in 1980 fully formed, but rather had existed sub-rosa in the consciousness of many American conservatives.

In the early 1970’s, Richard Nixon’s administration came up with the concept of the Managed Care Organizations, or MCOs, as the first real attempt to apply neoliberalism to health care. As we shall see, this would not be the first time that neoliberal ideas would be implemented into health care reform.

In Chapter Seven, of their book, Health Care under the Knife, authors Howard Waitzkin and Ida Hellander, discuss the origins of Obamacare and the beginnings of neoliberal health care reform. They point to the year 1994 as a significant one for reform worldwide, as Colombia enacted a national program of “managed competition” that was mandated and partially funded by the World Bank. This reform replaced their prior health system and was based mostly on public hospitals and clinics.

1994 was also the year when then First Lady, Hillary Clinton spearheaded a proposal like the one Colombia enacted that was designed by the insurance industry. I am sure you all remember the Harry and Sally commercials that ran on television that sank her proposal before it ever saw the light of day?

What ultimately became Obamacare was the plan implemented in 2006 in Massachusetts by Mitt Romney, but that was later disavowed when he ran for President in 2012. Waitzkin and Hellander write that even though these programs were framed to improve access for the poor and underserved, these initiatives facilitated the efforts of for-profit insurance companies providing “managed care.”

Insurance companies, they also said, profited by denying or delaying necessary care through strategies such as utilization review and preauthorization requirements; cost-sharing such as co-payments, deductibles, co-insurance, and pharmacy tiers; limiting access to only certain physicians; and frequent redesign of benefits.

These proposals, the authors state, fostered neoliberalism. They promoted competing for-profit private insurance corporations, programs and institutions based in the public sector were cut back, and possibly privatized. Government budgets for public-sector health care were cut, private corporations gained access to public trust funds, and public hospitals and clinics entered competition with private institutions, with budgets determined by demand rather than supply. Finally, prior global budgets for safety-net institutions were not guaranteed, and insurance executives made operational decisions about services, superseding the authority of physicians and other clinicians.

The roots of neoliberal health reform emerged from the Cold War military policy, and the authors cite economist Alain Enthoven providing much of the intellectual framework for those efforts. Enthoven was the Assistant Secretary of Defense under Robert S. McNamara during both the Kennedy and Johnson administrations. While he was at the Pentagon, between 1961 and 1969, he led a group of analysts who developed the “planning-programming-budgeting-system” (PPBS) and cost-benefit analysis, that intended to promote more cost-effective spending decisions for military expenditures. Enthoven became the principal architect, the authors indicate, of “managed competition”, which became the prevailing model for the Clinton, Romney, and Obama health care reforms, as well as the neoliberal reforms around the world.

The following table highlights the complementary themes in the military PPBS and managed competition in health care.

_____________________________________

Sources: See note 11, page 273.

Enthoven continued to campaign for his idea throughout the 1970s and 1980s and collaborated with managed care and insurance executives to refine the proposal after being rejected by the Carter administration. The group that met in Jackson Hole, Wyoming, which included Enthoven and Paul Ellwood, was funded by the five largest insurance corporations, as well as the 1992 Clinton presidential campaign, and wife Hillary’s Health Security Act.

The authors state that Barack Obama, while a state legislator in Illinois, favored a single payer approach, but changed his position as a presidential candidate. In 2008, he received the largest financial contributions in history from the insurance industry, that was three times more the contributions of his rival, John McCain.

The neoliberal health agenda, the authors write, including Obamacare, emerged as one component of a worldwide agenda developed by the World Bank, the International Monetary Fund, and other international financial institutions. The agenda to promote market-driven health care, facilitated access to public-sector health and social security trust funds by multinational corporations, according to Waitzkin and Hellander. The various attempts in the US by the Republican Party to privatize Social Security is an example of this agenda.

An underlying ideology claimed that corporate executives could achieve superior quality and efficiency by “managing” medical services in the marketplace, but without any evidence to support it, the authors contend. Health reform proposals from different countries have resembled one another closely and conform to a cookie-cutter template. Table 2 describes the six features of nearly all neoliberal reform initiatives.

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† Sources: patients, employers, public sector trust (“solidarity”) funds (the latter being “contributory” for employed workers, and “subsidized” for low income and unemployed).
‡ Sources: patients, public sector trust funds – Medicaid, Medicare.

The six features of neoliberal health reform are as follows:

  1. Organizations of providers – large, privately controlled organizations of health care providers, operate under direct control or strong influence of private insurance corporations, in collaboration with hospitals and health systems, may employ health care providers directly, or may contract with providers in a preferred network. In Obamacare, they are called Accountable Care Organizations (ACOs), supported only in Medicare, but Obamacare accelerated organizational consolidation in anticipation of broader implementation.

In this model, for-profit managed care organizations (MCOs) offer health plans competitively. In reality, competition is restrained by the small number of organizations large enough to meet the new laws’ financial and infrastructure requirements, as well as by the consolidation in the private insurance industry. They contract with or employ large numbers of health practitioners. Instead, physicians and hospitals are absorbed into MCOs.

  1. Organizations of purchasers – large organizations purchasing or facilitating the purchase of private health insurance, usually through MCOs. Under Obamacare, the federal and state health insurance “exchanges”—later renamed “marketplaces” to reflect reality of private, government-subsidized corporations—fulfill a similar role.
  2. Constriction of public hospitals and safety net providers – public hospitals at the state, county, or municipal levels compete for patients covered under public programs like Medicaid or Medicare with private, for-profit hospitals participating as subsidiaries or contractors of insurance companies or MCOs. With less public-sector funding, public hospitals reduce services and programs, and many eventually close. Under Obamacare, multiple public hospitals have closed or have remained on the brink of closure. Note: This is a subject I have written about in prior posts about Medicaid expansion.
  3. Tiered benefits packages – defined in hierarchical terms, minimum package of benefits viewed as essential, individuals and employers can buy additional coverage, poor and near poor in Medicaid eligible for benefits that used to be free of cost-sharing, but since Obamacare passed, states have imposed premiums and co-payments. Under Obamacare, various metal names—bronze, silver, gold, platinum, identify tiers of coverage, where bronze represents the lowest tier and platinum the highest.
  4. Complex multi-payer and multi-payment financing – financial flows under neoliberal health policies are complex (see Chart 7.1). There are four sources of these various financial flows.
    1. Outflow of payments – each insured person considered a “head” for whom a “capitation” must be paid to an insurance company or MCO.
    2. Inflow of funds – funds for capitation payments come from several sources. Premiums paid by workers and their families, contributions from employers is a second source. Public-sector trust funds are a third source, co-payments and deductibles constitute a fourth source, and taxes are a fifth source.
  5. Changes in the tax code – neoliberal reforms usually lead to higher taxes because they increase administrative costs and profits, Obamacare reduces tax deductions and imposes a tax for so-called Cadillac insurance plans. In addition, it calls for penalties for those who do not purchase mandatory coverage, administered by the IRS. I was unable to get on the ACA because I had not filed a return in several years due to long-term unemployment because of the financial collapse of 2007/2008, and the subsequent jobless recovery.

Chart 7.1 Financial Flows under Neoliberal Health Reform

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*Purchase of insurance policies for employers and patients mediated by large organizations of health care purchasers.

What is the outlook for single payer in the US, the authors ask?

They cite national polls that show that about two-thirds of people in the US favor single payer. See Joe Paduda’s post here.

If the US were to adopt single payer, the PNHP proposal would provide coverage for all needed services universally, including medications and long-term care, no out-of-pocket premiums, co-payments, or deductibles; costs would be controlled by “monopsony” financing from a single, public source, would not permit competing private insurance and would eliminate multiple tiers of care for different income groups; practitioners and clinics would be paid predetermined fees for services without and need for costly billing procedures; hospitals would negotiate an annual global budget for all operating costs, for-profit, investor-owned facilities would be prohibited from participating; most nonprofit hospitals would remain privately owned, capital purchases and expansion would be budgeted separately, based on regional health-planning goals.

Funding sources would include, they add, would include current federal spending for Medicare and Medicaid, a payroll tax on private businesses less than what businesses currently pay for coverage, an income tax on households, with a surtax on high incomes and capital gains, a small tax of stock transactions, while state and local taxes for health care would be eliminated.

From the viewpoint of corporations, the insurance and financial sectors would lose a major source of capital accumulation, other large and small businesses would experience a stabilization or reduction in health care costs. Years ago, when I first considered single payer, I realized that if employers no longer had to pay for health care for their employees, they could use those funds to employ more workers and thus limit the impact of recessions and jobless recoveries.

So how do we move to single payer and beyond?

According to the authors, and to this reporter, the coming failure of Obamacare will become a moment of transition in the US, where neoliberalism has come home to roost. This transition is not just limited to health care. The theory of Spiral Dynamics, of which I have written about in the past, predicts that at the final stage of the first tier, or Existence tier, the US currently occupies, there will be a leap to the next stage or tier, that being the Being tier, where all the previous value systems have been transcended and included into the value systems of the Being tier.

We will need to address, the authors contend, with the shifting social class position of health professionals and to the increasingly oligopolistic and financialized character of the health insurance industry. The transition beyond Obamacare, they point out, will need to address also the consolidation of large health systems. Obamacare has increased the flow of capitated public and private funds into the insurance industry and extended the overall financialization of the global economy.

The authors conclude the chapter by declaring that as neoliberalism draws to a close, and as Obamacare fails, a much more fundamental transformation needs to reshape not just health care, but also the capitalist state and society.

To sum it all up, all the attempts cure the ills of health care by treating the symptoms and not the cause of the disease will not only fail, but is only making the disease worse, and the patient getting sicker. We need radical intervention before the patient succumbs to the greed and avarice of Wall Street, big business, and those whose stake in the status quo is to blame for the condition the patient is in in the first place.

Therefore, Obamacare is the last stage of neoliberal health care reform.

Three Strategies for Improving Social Determinants of Health

A shoutout to Irving Stackpole for bringing this to our attention today on LinkedIn. This is an important topic that can address the serious issue of poverty in our inner cities.

The topic of food deserts first gained national attention thanks to the efforts of former First Lady, Michelle Obama, who not only created a vegetable garden on the White House grounds, but championed the creation of other gardens in inner city elementary schools.

One in particular was created at a Washington, DC school, and Mrs. Obama invited Chef Robert Irvine of Restaurant: Impossible to cook for inner city school children at Horton’s Kids, a local community center that provides after-school meals for kids.

So an article last week in Managed Care magazine, discussed the three strategies health care systems and payer organizations are trying to address patients’ social needs.

The first strategy, Tackle a neighborhood, focuses on the work ProMedica, a 13-hospital not-for-profit system in Toledo, Ohio is undertaking.

In the UpTown neighborhood of Toledo, the average median household income is less than $21,000 a year, and more than a quarter of all adults have not completed high school. Few residents have homes or vehicles, and healthy food options are hard to come by.

One way they are dealing with the food deficit in the neighborhood is by opening a grocery store called Market on the Green, and is a joint project of ProMedica and the Ebeid Institute.

They also initiated a job-training program, a financial opportunity center, and personal-finance advice and programs.

Last year, ProMedica doubled down and announced a 10-year plan to invest $50 million to create a national model for neighborhood revitalization. In March, they announced a partnership with a New York City-based nonprofit to invest additional capital to spur further economic growth.

Lastly, they expanded their screened 4,000 Medicaid patients who use the food clinic, and found that emergency department utilization decreased by 3%, and 30-day readmission by 53%, with a modest increase in utilization of primary care.

They also expanded screening  to include housing, transportation, and other social needs.

The second strategy is Tackle the top problems.

Here, Humana has been working on its Bold Goal, a population health strategy to improve the health of the communities it serves by 20%.

Humana wants to increase the number of “healthy days” in seven markets: Louisville, KY; Knoxville, TN; San Antonio, TX; Broward County, Fl; Baton Rouge, La; New Orleans; and Tampa Bay.

In the first year, the San Antonio market showed a 9% increase in healthy days, which was attributed to several initiatives, namely a telepsychiatry pilot to increase access to behavioral health services, food insecurity screening at primary are offices, and a collaboration with other organizations to improve diabetes management,

Finally, the third strategy is Develop a social determinants workforce.

Trinity Heatlh, a 93-hospital health care system in Michigan, and one of the largest Catholic systems in the country, has been addressing their patients’ social needs through a series of small experiments.

Trinity’s strategy is to develop a cadre of community health workers who will use pathways, regimented, evidence-based multistep protocols to help individuals address their specific needs.

Trinity found that by focusing on patients covered by Medicare, Medicaid, or both, and assisted by community health workers, they reduced their emergency department and hospital utilization considerably.

Trinity also hired AmeriCorps workers to serve as community health workers in nine markets. They focused on the social determinants of health of a narrow group of patients: high-utilizing eligibles in an ACO or other at-risk contract.

The strategies these organizations are undertaking are bold initiatives that show some promise of success, but time will tell just how successful they will be.

Yet, in an era of huge tax cuts going to the wealthy, and budget cuts  eliminating many government programs or severely limiting them, these companies are taking decisive action to reverse decades of neglect and despair in our inner cities.

But they won’t be effective unless there is greater cooperation from the communities they wish to serve, and from the rest of the health care community, and those in other institutions.

There is an accompanying story here: Social Determinants of Health: Stretching Health Care’s Job Description.

Rural Hospitals to Fail If Medicaid Expansion Ends

In April of 2015, I wrote the following post, Hospital Closures Due to Failure to Expand Medicaid.

This morning, Health Affairs posted a brief, Ending Medicaid Expansion Would Cause Rural Hospitals to Go Under.

As the current regime in Washington, and its allies in Congress slowly dismantle the ACA, rolling back Medicaid expansion will lead to rural hospitals closing, and rural patients being forced to travel long distances to get to a hospital, or to forgo medical at all.

What impact this will have on the entire health care sector is too early to tell, and what this may mean for workers’ comp, is also speculative, but it can’t be good if hospitals in the heartland go out of business.

Some way to make America great again. On the backs of, and on the health of, rural Americans who voted for this clown.