Category Archives: Social determinants of health

Useless Health Insurance Companies

Don McCanne’s Quote-of-the-Day brings us an article from the Los Angeles Times by Michael Hiltzik about how useless health insurance companies are.

Los Angeles Times
August 5, 2019
Health insurance companies are useless. Get rid of them
By Michael Hiltzik

 

The most perplexing aspect of our current debate over healthcare and health coverage is the notion that Americans love their health insurance companies.

This bizarre idea surfaced most recently in the hand-wringing over proposals to do away with private coverage advocated by some of the candidates for the Democratic nomination for president. Oddly, this position has been treated as a vote-loser.

During the first round of televised debates on July 30 and 31, only four of the 20 candidates raised their hands when asked if they would ban private insurers as part of their proposals for universal coverage: Sens. Elizabeth Warren of Massachusetts, Bernie Sanders of Vermont and Kamala Harris of California, and New York Mayor Bill de Blasio. Harris later backed away, releasing a “Medicare for all” proposal that would accommodate private insurers at least for the first 10 years.

Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential.

HEALTH INSURANCE EXPERT WENDELL POTTER

She should have stood her ground. The truth is that private health insurers have contributed nothing of value to the American healthcare system. Instead, they have raised costs and created an entitled class of administrators and executives who are fighting for their livelihoods, using customers’ premium dollars to do so.

“Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential,” says Wendell Potter. He should know, since he spent decades as a corporate communications executive in the industry, including more than 10 years at Cigna.

The insurers’ success in making themselves seem essential accounts for the notion that Americans are so pleased with their private coverage that they’ll punish any politician who dares to take it away. But the American love affair with private insurance warrants close inspection.

Let’s start by examining what the insurers say are their positive contributions to healthcare. They claim to promote “consumer choice,” simplify “the health care experience for individuals and families,” address “the burden of chronic disease” and harness “data and technology to drive quality, efficiency, and consumer satisfaction.” (These claims all come from the website of the industry’s lobbying organization, America’s Health Insurance Plans (AHIP).

They’ve achieved none of these goals. The increasingly prevalent mode of health coverage in the group and individual markets is the the narrow network, which shrinks the roster of doctors and hospitals available to enrollees without heavy surcharges. The hoops that customers and providers often must jump through to get claims paid impose costly complexity on the system, not simplicity. Programs to manage chronic diseases remain rare, and the real threat to patients with those conditions was lack of access to insurance (until the Affordable Care Act made such exclusion illegal).

Private insurers don’t do nearly as well as Medicare in holding down costs, in part because the more they pay hospitals and doctors, the more they can charge in premiums and the more money flows to their bottom lines. They haven’t shown notable skill in managing chronic diseases or bringing pro-consumer innovations to the table.

pareto

The vast majority of Americans have very little need for medical care in any given year; that’s why most people are satisfied with their coverage. But what if they have a big claim?
(NIHCM)

 

Insurers cite these goals when they try to get mergers approved by government antitrust regulators. Anthem and Cigna, for example, asserted in 2016 that their merger would produce nearly $2 billion in “annual synergies,” thanks to improved “operational” and “network efficiencies.”

The pitch has a long history. The architects of a wave of health insurance mergers in the 2000s also proclaimed a new era of efficient technology and improved customer service, but studies of prior mergers show that this nirvana seldom comes to pass. The best example may be that of Aetna’s 1996 merger with U.S. Healthcare in a deal it hoped would give it access to the booming HMO market.

According to a 2004 analysis by UC Berkeley health economist James C. Robinson, the merger became a “near-death” experience for Aetna. The deal was expected to bring about “millions in enrollment and billions in revenue to pressure physicians and hospitals” to accept lower reimbursement rates, he wrote.

“The talk was all about complementarities, synergies, and economies of scale… The reality quickly turned out to be one of incompatible product designs, operating systems, sales forces, brand images, and corporate cultures.” Aetna surged from 13.7 million customers in 1996 to 21 million in 1999, but profits collapsed from a margin of nearly 14% in 1998 to a loss in 2001.

Even when they don’t happen, insurance merger deals cost customers billions of dollars. That’s what happened when two proposed deals — Aetna/Humana and Anthem/Cigna — broke down on a single day in 2017. The result was that Aetna owed Humana $1.8 billion and Anthem owed Cigna $1.85 billion in breakup fees — money taken out of the medical treatment economy and transferred from one set of shareholders to another.

In reality, Americans don’t like their private health insurance so much as blindly tolerate it. That’s because the vast majority of Americans don’t have a complex interaction with the healthcare system in any given year, and most never will. As we’ve reported before, 1% of patients account for more than one-fifth of all medical spending and 10% account for two-thirds. Fifty percent of patients account for only 3% of all spending.

Most families face at most a series of minor ailments that can be routinely managed — childhood immunizations, a broken arm here or there, a bout of the flu. The question is what happens when someone does have a complex issue and a complex claim — they’re hit by a truck or get a cancer diagnosis, for instance?

“We gamble every year that we’re going to stay healthy and injury-free,” Potter says. When we lose the gamble, that’s when all the inadequacies of the private insurance system come to the fore. Confronted with the prospect of expensive claims, private insurers try to constrain customers’ choices — limiting recovery days spent in the hospital, limiting doctors’ latitude to try different therapies, demanding to be consulted before approving surgical interventions.

Indeed, the history of American healthcare reform is largely a chronicle of steps taken to protect the unserved groups from commercial health insurance practices.

When commercial health insurance became insinuated into the American healthcare system following World War II via employer plans, it quickly became clear who was left behind — “those who were retired, out of work, self-employed, or obliged to take a low-paying job without fringes,” sociologist Paul Starr wrote in his magisterial 1982 book, “The Social Transformation of American Medicine.”The process even left those groups worse off, Starr observed, because insurance contributed to medical inflation while insulating only those with health plans. “Government intervention was required just to address the inequities.”

Insurers wouldn’t cover the aged or retirees, so Medicare was born in 1965. Insurers refused to cover kidney disease patients needing dialysis, so Congress in 1973 carved out an exception allowing those patients to enroll in Medicare at any age. (So much for addressing the “burden of chronic disease.”)

Individual buyers were charged much more for coverage than those buying group plans through their employers — or barred from the marketplace entirely because of their medical conditions — the Affordable Care Act required insurers to accept all applicants and, as compensation, required all individuals to carry at least minimal coverage.

The health insurance industry’s most telling contribution to the debate over healthcare reform has been “to scare people about other healthcare systems,” Potter told me. As a consequence, discussions about whether or how to remove private companies from the healthcare system are chiefly political, not practical.

The Affordable Care Act allowed private insurers to continue playing a role in delivering coverage not because they were any good at it but because their wealth and size made them formidable adversaries to reform if they chose to fight it. They were sufficiently mollified to remain out of the fray, but some of the big insurers then did their best to undermine the individual insurance exchanges once they were launched in 2015.

Even as individual Americans fret over losing their private health insurance, big employers have begun to see the light. Boeing, among other big employers, is experimenting with bypassing health insurers as intermediaries with providers by contracting directly with major health systems in Southern California, Seattle and other regions where it has major plants. It would not be surprising to see the joint venture of Amazon, Berkshire Hathaway and JP Morgan Chase try a similar approach in its quest to bring down costs.

That’s an ironic development, since the private insurers first entered the market precisely by offering to play the role of intermediaries for big employers. But instead of fulfilling the promise of efficiency and cost control, they became rent-seeking profiteers themselves.

There’s no doubt that it will take years to wean the American healthcare system off the private insurance model; Kamala Harris’s proposal may be merely a recognition of the necessary time frame. It’s true that some countries with universal healthcare systems preserve roles for private insurance, including coverage for services the government chooses to leave out of its own programs or providing preferential access to specialists, at a price.

But the private insurers’ central position in America’s system is an anachronism dating back some 75 years. The sooner it’s dispensed with, the better — and healthier — America will be. The next time a debate moderator asks presidential candidates if they favor doing away with private insurance, let’s see all the hands go up.

Medical Mystery: Something Happened to the U.S. Health System After 1980 | The Incidental Economist

Good morning all. While perusing my LinkedIn feed, I found this article from May of last year, and thought it would be a perfect addition to the series of articles posted last week about Medicare for All/Single Payer, and why opposition to it is more harmful than the alleged or imagined fear-mongering we are seeing from many quarters.

This is especially significant in light of my post last week, Health Care Is Not a Market, and as the article below suggests, the US health care system diverged exactly at the time of the election of Ronald Reagan in 1980, and the introduction of pro-market forces, supply-side economics.

So it is no coincidence that as Austin Frakt writes, that prices went up, while health outcomes went down, and that socioeconomic status and other social factors exert larger influences on longevity.

Here is the article:

The following originally appeared on The Upshot (copyright 2018, The New York Times Company). Research for this piece was supported by the Laura and John Arnold Foundation.

Source: Medical Mystery: Something Happened to the U.S. Health System After 1980 | The Incidental Economist

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.

Social Determinants Of Health: A Public Health Concept In Conflict

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

Universal Health Care in Reach? Not So Fast

The magazine, The Economist, published a ten-page special report in their April 28th edition on universal health care worldwide.

The report, which one social media commenter said was a perfect example of title and context differentiation, and gave no data or reason why health care was closer to being universal, is an example of a neoliberal publication going out on a limb with an issue vital to all human beings, and giving it short-shrift.

Throughout the report, The Economist mentions the World Bank and the World Health Organization (WHO), as well as the Gates Foundation as international organizations involved with public health in developing countries. The report contains statistics on the percentage of people in certain countries who do not have insurance, and other statistics to paint a bleak picture of health care in developing countries.

What the report fails to do is mention that it is exactly the World Bank, the IMF, international financial organizations, philanthropies like the Gates and other foundations, and the WHO, that have been responsible for preventing these countries from improving their health care systems.

Chapter Nine of the Waitzkin, et al., book previously reviewed in this blog, discusses in detail how these institutions influenced health care around the world for the benefit of multinational corporations in the developed world, and to the detriment of the health care in the Global South.

In particular, the WHO, which began in 1948 as a sub-organization of the United Nations, lost considerable funding due to ideological opposition to several programs operated by sub-organizations of the UN, and because the Reagan administration withheld annual dues. The UN began experiencing increasing budgetary shortfalls, which was passed onto organizations like the WHO.

But to the rescue, came the World Bank, and with this influx of private funds, the agenda of WHO changed to match that of the World Bank, international financial institutions and trade agreements. It was in the interest of these entities that health care be carried out in a vertical, top-down approach that left out key parts of the health care services needed in developing countries, namely surgery and concentrated on addressing infectious diseases like AIDS, malaria, and tuberculosis.

But there is another reason why public health in developing countries is in such a dismal state, and it has to do with the debt crisis these nations and others were subjected to by the nations of the Global North and the World Bank, IMF and international financial institutions.

According to the blog, One.org, “Developing countries spent years repaying billions of dollars in loans, many of which had been accumulated during the Cold War under corrupt regimes. Years later, these debts became a serious barrier to poverty reduction and economic development in many poor countries. Governments began taking on new loans to repay old ones and many countries ended up spending more each year to service debt payments than they did on health and education combined.

After many years of activism on the part of advocates for the poor and other activists, the nations of the Global North, through such organizations as the G8, the IMF and World Bank, decide to abolish debts worth billions of dollars owed by developing countries. Yet, despite this action, data in the World Bank’s global development finance 2012 report shows total external debt stocks owed by developing countries increased by $437 billion over 12 months to stand at $4 trillion at the end of 2010, the latest period of available data, according to the Guardian.

Third world debt was a serious issue when I was in college studying international relations and foreign policy, and I was aware of the efforts to reduce or eliminate this debt, so when I read in The Economist that the World Bank and WHO are engaged in public health issues around the world, I have to ask myself how is it possible that the very institutions responsible for the state of affairs experienced in developing countries as pertains to health care, are the very same institutions undoing the wreckage they created. Or at least not in ways that are advantageous to the citizens of those countries.

Instead of the vertical, top-down orientation these institutions are engaged in, a broad, horizontal orientation needs to be implemented that will radically alter the health care systems of these countries and provide all of their people with truly universal health care.

Lastly, The Economist looks at the US, and rightly points to our stubborn adherence to individualism and even quotes Republican congressman, Jason Chaffetz, who said, “Americans have choices.And they’ve got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.”

Many Republicans, like Rep. Chaffetz, says The Economist, believe health care is not a right but something people choose to buy (or not) in a marketplace.  I can tell you, dear readers, I did not choose to have End-Stage Renal Disease, nor did I choose to be long-term unemployed (that is due to neoliberal economic policies and to the financial meltdown caused by the very institutions that have a negative impact on universal health care), so Rep. Chaffetz and his Republican colleagues are wrong. And besides, you can’t buy health, as we all get sick and we all die. What you buy is a policy, but policies are not the same as care.

One other reason The Economist cites for the US being an outlier in providing universal care is resistance to reform by powerful interest groups.

I don’t believe this report did anything to move the debate forward towards universal health care, either here in the US, or around the world. It really did not cover any new ground, and its prediction for health care universally achieved is either wishful thinking or a delusion. Either way, until the economic order changes, nothing in health care will.

 

What’s Really Wrong With Health Care?

Book Review

Health Care Under the Knife: Moving Beyond Capitalism for Our Health

by Howard Waitzkin and the Working Group on Health Beyond Capitalism

Monthly Review Press
e-book: $18.00
Paperback: $27.00
Hard cover: $45.00

Americans commemorated the assassination of Martin Luther King fifty years ago on Wednesday. Two years earlier, Dr. King, in March 1966, said the following during a press conference in Chicago at the second convention of the Medical Committee for Human Rights (MCHR):

“…Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”

The part of the quote up to the word ‘inhuman’ begins the Introduction of a new book I just began reading called, Health Care Under the Knife: Moving Beyond Capitalism for Our Health by Howard Waitzkin and the Working Group on Health Beyond Capitalism, published by Monthly Review Press, the publishing arm of the Monthly Review, an Independent Socialist magazine.

Those of you who know me, and those of you who have read many of my previous posts, know that my educational background is in the Social Sciences, as my B.A, is in Political Science and History, with Sociology and African-American Studies thrown in, along with some Humanities coursework. My M.A. is in History, with emphasis on American Social History, especially post-Civil War until the mid to late 20th century. In addition, I also have a Master’s degree in Health Administration (MHA).

But what you may not know is that my leanings have been to the far left, and I am still proudly and defiantly so, even if I have tempered my views with age and new insights. I think that is called wisdom.

So, as I set out to read this book, much of the material presented in it will not be new to me, but will be perhaps new to many of you, especially those of you who got their education in business schools, and were fed bourgeois nonsense about marketing, branding, and other capitalist terms that are more apropos for selling automobiles and appliances and such, but not for health care, as this book will prove.

In this book, there will be terms that many of you will either find annoying, depending on your own personal political leanings, or that you are unfamiliar with. Words such as alienation of labor, commodification, imperialism, neoliberalism, and proletarianization may make some of you see red. So be it. Change will not occur until many of you are shaken out of your lethargy and develop your class consciousness.

“Capital is reckless of the health or length of life of the laborer, unless under compulsion from society.” Karl Marx

While the publisher of the book is an independent socialist foundation, it is no means a Marxist or Communist organization. And from my perusal of the names of the contributors to the chapters of the book, I have found that they are all health care professionals or academics, as well as activists.

Two of the contributors of one chapter, David Himmelstein and Steffie Woolhandler, are familiar to many in the health care industry, as they have co-authored many peer reviewed articles in health care journals that I have cited in my previous blog posts.

Be warned. This book may piss you off. Too bad. The future of health care is at stake, as is the health of every man, woman, and child in the U.S. and around the world.

This will probably be true no matter what part of the health care industry you work in. Physicians, insurance company personnel, pharmaceutical company executives, Wall Street investors and money managers, service providers, vendors, consultants and many others will discover inconvenient truths about the businesses that provide their livelihood. As stakeholders in the status quo, you will be resistant to the prescriptions the writers offer for correcting the mistakes of the past, and the recommendations they suggest for the future of health care.

This book will not only be relevant to the health care industry, but also to the workers’ compensation and medical travel industries, as each is a subset of health care.

And if you do get upset or angry at me for what I have to say about health care, then you are part of the problem as to why health care in the U.S. is broken. Those of you around the world will also learn that your own countries are moving in a direction that sooner or later will result in your health care system mirroring our own, as the authors will point out.

This is a book that will shake you to your core. So, sit back, relax, and keep an open mind. It’s about to be blown.

The book is divided into five parts, with each part containing at most five chapters, as in Part Five, or two chapters, as in Part Two. Parts Three and Four, each contain four chapters. Part One deals with Social Class and Medical Work, and focuses on doctors as workers, the deprofessionalization and emerging social class position of health professionals, the degradation of medical labor and the meaning of quality in health care, and finally, the political economy of health reform.

Throughout the book, they ask questions relating to the topics covered in each chapter, and in Part One, the following questions are asked:

  • How have the social-class positions of health workers, both professional and non-professional, changed along with changes in the capitalist global economy?
  • How has the process of health work transformed as control over the means of production and conditions of the workplace has shifted from professionals to corporations?

These questions are relevant since medicine has become more corporatized, privatized, and financialized. The author of the second chapter, Matt Anderson, analyzes the “sorry state of U.S. primary care” and critically examines such recently misleading innovations such as the “patient-centered medical home”, “pay for performance”, the electronic medical record, quantified metrics to measure quality including patient satisfaction (“we strive for five”), and conflicts of interest as professional associations and medical schools receive increasing financial support from for-profit corporations.

Part One is concludes with Himmelstein and Woolhandler responding to a series of questions put to them by Howard Waitzkin about the changing nature of medical work and how that relates to the struggle for a non-capitalist model of a national health program. Himmelstein and Woolhandler comment on the commodification of health care, the transformation that has occurred during the current stage of capitalism, the changing class position of health professionals, and the impact of computerization and electronic medical records.

Part Two focuses on the medical-industrial complex in the age of financialization. Previous posts of mine this year and last, reference the medical-industrial complex, so my readers will be familiar with its usage here. In this section, the authors tackle the following questions:

  • What are the characteristics of the current “medical industrial complex,” and how have these changed under financialization and deepening monopolization?

Two corollary questions are raised as follows:

  • Are such traditional categories as the private insurance industry and pharmaceutical industry separable from the financial sector?
  • How do the current operations of those industries reflect increasing financialization and investment practices?

Once again, Matt Anderson authors the first chapter in Part Two, this time with Robb Burlage, a political economist and activist. Anderson and Burlage analyze the growing similarities and overlaps between the for-profit and so-called not-for-profit sectors in health care, considering especially the conversion of previously not-for-profit corporations such as Blue Cross and Blue Shield to for-profit.

The second chapter in Part Two is authored by Joel Lexchin, an emergency care physician and health policy researcher in Canada and analyzes monopoly capital and the pharmaceutical industry from an international perspective.

Part Three looks at the relationships between neoliberalism, health care and health. Before I go any further, let me provide the reader with a definition of neoliberalism in case the authors assume that those who read this book understand what it is.

According to Wikipedia, Neoliberalism or neo-liberalism 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.

These neoliberal policies have been associated in the U.S. with the Republican Party and the Conservative movement since the election of Ronald Reagan. In the UK, the rise of Thatcherism ended the long dominance of the Labor Party’s left-wing until Tony Blair’s New Labor took over. Bill Clinton’s election in the U.S. in 1992, diminished some of these policies, and implemented others such as welfare reform, a goal Republicans had wanted to achieve for decades.

Returning to Part Three, the questions asked here are:

  • What is the impact of neoliberalism on health reforms, in the United States and in other countries?
  • What are the ideological assumptions of health reform proposals and how are they transmitted?
  • What are the effects of economic austerity policies on health reform and what are the eventual impacts on health outcomes?

In the next chapter, Howard Waitzkin and Ida Hellander, a leading health policy researcher and activist, trace the history of the Affordable Care Act initially developed by economists in the military during the Vietnam War. International financial institutions, the authors say, especially the World Bank, promoted a boilerplate for neoliberal health care reforms, which focused mainly on privatization of services previously based in the public sector and on shifting trust funds to private for-profit insurance companies.

Colombia’s health reform of 1994, Hillary Clinton’s in that year as well, Mitt Romney’s plan in Massachusetts in 2006, which led to the ACA, are examples cited by the authors. The chapter also clarifies the ideological underpinnings of the neoliberal model and shows that the model has failed to improve access and control costs, according to the authors.

Economic austerity is closely linked to neoliberalism and have led to drastic cutbacks in health services and public health infrastructure in many countries. As I have recently written in my post, Three Strategies for Improving Social Determinants of Health, economic austerity policies have also affected health outcomes through increased unemployment, food insecurity, unreliable water supplies (Flint, MI), and reduced educational opportunities. Recent teacher protests in West Virginia, Oklahoma and other states are examples of this.

In the second chapter in Part Three, Adam Gaffney and Carles Muntaner, focus on social epidemiology, especially the impacts of economic policies on health and mental health outcomes. They also document the devastating effects of austerity in Europe, focusing on Greece, Spain and England. The authors analyze four dimensions of austerity:

1) constriction of the public-sector health system, 2) retreat from universalism, 3) increased cost sharing, and 4) health system privatization.

This trend would seem to have a negative effect on medical travel from Europe and to Europe, as Europe’s health care systems, long touted as a less expensive alternative to medical care in the U.S., begins to suffer.

Part Four examines the connections between health and imperialism historically and as part of the current crises. The question in this part is:

  • What are the connections among health care, public health, and imperialism, and how have these connections changed as resistance to imperialism has grow in the Global South?

The authors are referring to those countries in the Southern hemisphere from Africa, Asia, and Latin America as the Global South. The Global North refers to Europe and North America, and some other industrialized and advanced countries in the Northern hemisphere.

The authors in Part Four focus on the forces and institutions that have imposed a top-down reform of health care in the Global South. Such organizations as the Carnegie, Rockefeller, and Gates foundations, the World Bank and International Monetary Fund, trade agreements such as NAFTA, CAFTA, TPP, TiSA, and health organizations as the World Health Organization (WHO) and the Pan American Health Organization (PAHO) are all termed “philanthrocapitalism” by the authors, and have implemented policies that have weakened public health standards and favored private corporations.

The final part, Part Five focuses on the road ahead, i.e., the contours of change the authors foresee and the concrete actions that can contribute to a progressive transformation of capitalist health care and society.

The authors address these questions:

  • What examples provide inspiration about resistance to neoliberalism and construction of positive alternative models in the Global South?
  • Because improvements in health do not necessarily follow from improvements in health care, how do we achieve change in the social and environmental determinants of health?
  • How does progressive health and mental health reform address the ambiguous role of the state?
  • What is to be done as Obamacare and its successor or lack of successor under Trump fail in the United States?

Howard Waitzkin and Rebeca Jasso-Aguilar analyze a series of popular struggles that focused on the privatization of health services in El Salvador, water in Bolivia, as well as the ongoing struggle to expand public health services in Mexico. These struggles are activities David and Rebeca participated in during the past decade.

These scenarios demonstrate an image of diminishing tolerance among the world’s people for the imperial public health policies of the Global North and a demand for public health systems grounded in solidarity rather than profit.

In the U.S., the road ahead will involve intensified organizing to achieve the single-payer model of a national health program, one that will provide universal access and control costs by eliminating or reducing administrative waste, profiteering, and corporate control.

Gaffney, Himmelstein, and Woolhandler present the most recent revision of the single-payer proposal developed by Physicians for a National Health Program (PNHP). They analyze the three main ways that the interests of capital have encroached on U.S. health care since the original proposal:

1) the rise of for-profit managed care organizations (MCOs); 2) the emergence of high-deductible (“consumer-directed”) health insurance, and 3) the entrenchment of corporate ownership.

The authors offer a critique of Obamacare, explain and demystify innovations as Accountable Care Organizations, the consolidation and integration of health systems, something yours truly has discussed in earlier posts as they relate to workers’ comp, and the increasing share of costs for patients.

The next two chapters concern overcoming pathological normalcy and confronting the social and environmental determinants of health, respectively. Carl Ratner argues, that mental health under capitalism entails “pathological normalcy.” Day-to-day economic insecurities, violence, and lack of social solidarity generates a kind of false consciousness in which disoriented mental processes become a necessary facet of survival, and emotional health becomes a deviant and marginalized condition.

Such conditions of life as a polluted natural environment, a corrupt political system, an unequal hierarchy of social stratification, an unjust criminal justice system, violent living conditions due to access of guns, dangerous working conditions, and so forth, Ratner dissects as the well-known crises of our age in terms of the pathologies that have become seen as normal conditions of life.

Next, Muntaner and evolutionary biologist Rob Wallace show how social and environmental conditions have become more important determinants of health than access to care. They emphasize struggles that confront social determinants through changes in broad societal polices, analyze some key environmental determinants of health including unsafe water (Flint again), capitalist agribusiness practices, and deforestation in addition to climate change. And they refer to the impact these have on emergent and re-emergent infectious diseases such as Ebola, Zika and yellow fever.

Lastly, Waitzkin and Gaffney try to tackle the question of “what is to be done.” They outline four main priorities for action in the U.S. and other countries affected by the neoliberal, corporatized, and commodified model of health care during the age of Trump:

  • a sustained, broad-based movement for a single-payer national health program that assures universal access to care and drastically reduces the role of corporations and private profit, 2) an activated labor movement that this time includes a well-organized sub-movement of health professionals such as physicians, whose deteriorated social-class position and proletarianized conditions of medical practice have made them ripe for activism and change, 3) more emphasis on local and regional organizing at the level of communal organizations…and attempted in multiple countries as a central component in the revolutionary process of moving “beyond capital”, and 4) carefully confronting the role of political parties while recognizing the importance of labor or otherwise leftist parties in every country that has constructed a national health program, and understanding that the importance of party building goes far beyond electoral campaigns to more fundamental social transformation.

In their book, the authors try to answer key and previously unresolved questions and to offer some guidance on strategy and political action in the years ahead. They aim to inform future struggles for the transformation of capitalist societies, as well as the progressive reconstruction of health services and public health systems in the post-capitalist world.

Throughout this review, I have attempted to highlight the strengths of the book by touching upon some of the key points in each chapter.

If there is a weakness to the book, it is that despite the impressive credentials of the authors, they like many other authors of left-of-center books, cling to an economic determinism as part of their analysis, which is based on theories that are more than one hundred years old.

As I stated in the beginning of this review, my views have been tempered by examining and incorporating other theories into my consciousness. One theory that is missing here is Spiral Dynamics.

Spiral Dynamics is a bio-psycho-social model of human and social development. It was developed by bringing together the field of developmental psychology with evolutionary psychology and combines them with biology and sociology.

In Spiral Dynamics, biology is concerned with the development of the pathways of the brain as the adult human moves from lower order thinking to higher order thinking. The social aspect is concerned with the organizational structure formed at each stage along the spiral. For example, when an individual or a society is at the Beige vMeme, or Archaic level, their organization structure is survival bands, as seen in the figure below.

At the Purple vMeme, or Mythic level, the organizational structure is tribal, and so on. There is, among the authors of the book, an evolutionary biologist, but it is not clear if he is familiar with this theory and what it can bring into the discussion at hand.

It would not only benefit the authors, but also the readers to acquaint themselves of this valuable theory which would present an even more cogent argument for better health care. As the book concludes with a look at the future of health care after capitalism, knowing the vMemes or levels beyond current levels will enhance the struggle.

As I continue reading the book, I hope to gain greater insight into the problems with privatized, corporatized, free-market capitalist health care. My writings to date in my blog has given me some understanding of the issues, but I hope that the authors will further my understanding.

I believe that anyone who truly wants to see the U.S. follow other Western nations who have created a national health program, whether they are politicians like Bernie Sanders, his supporters, progressives, liberals, and yes, even some conservatives who in light of the numerous attempts to repeal and replace the ACA, have recognized that the only option left is single-payer. Even some business leaders have come out and said so.

I recommend this book to all health care professionals, business persons, labor leaders, politicians, and voters interested in moving beyond capital and realizing truly universal health care and lower costs.

 

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.