What the Heck Happened to Surprise Billing Legislation? (Or, it’s never too late for the lobbyists to win.)

With constituents pressing for something to remedy unexpected liabilities incurred from “surprise” medical bills, it was expected that surprise medical bill legislation would pass federally in December 2019 as part of an end-of-year legislation package. House and Senate committees had worked for months on consensus legislation that was ready to go, but that fell through at the last moment. What happened?

Some background on the issue: Surprise bills are something of a battleground between payers (insurers) and providers (doctors/hospitals). Insurers want to lower bills, and providers want to raise them. More and more, hardball is being played. If large groups of specialty providers remain out-of-network, they can often make a great deal more money than if they signed a contract for a number agreeable to the insurer. Patients – who can get nightmarish huge bills and be legally liable for them – are the roadkill in this tug-of-war. Private equity firms, who are now buying up group medical practices on the assumption that they can increase earnings substantially, have recently become a major player in the dynamic. Dr. Poses had a good post in September on their role and on their lobbying/advertising efforts. Private equity firms like Blackstone and KKR put a TON of money into the radio and TV ads that urged people to call their legislators to oppose "government rate-setting."

We’re not talking chump change, here. A recent analysis showed that surprise billing charges in excess of negotiated rates amount to as much as FORTY BILLION dollars annually.

Surprise billing legislation – state and federal - to date has taken two approaches. One approach is to fix the bill with out-of-network doctors based in some way on what an in-network doctor makes. This “benchmarking” approach advantages the insurance companies and self-funded employers.

The other is to rely on arbitrators to settle the dispute about amounts between provider and insurers. Experience has shown that this is in practice highly advantageous to the provider – to hospitals and to specialty groups (and in some cases to their private equity investors). This second approach drives up already-high U.S. medical costs. This major downside, in my opinion, makes it far more in the public interest to lean toward the benchmarking type of solution, while striving for fairness.

The bipartisan consensus agreement, known as the Murray-Alexander bill after Democrat Patty Murray and Republican Lamar Alexander, was initially based on a benchmarking approach, but after compromises that were made, had room for outside arbitration for amounts over $750. The Congressional Budget Office estimated that its passage would save TWELVE BILLION dollars in insurer medical costs, enabling lowering of premiums (this does not even include out-of-pocket patient savings). But, of course, those twelve billion dollars in saved costs are also twelve billion dollars in lowered revenue to providers and their owners.

And so, this bipartisan deal was torpedoed at the last moment by another bipartisan team, Democrat Richard Neal (House Ways and Means committee chair) and Republican Kevin Brady. Everything also indicates that Senate Minority Leader Chuck Schumer – who pushed Murray to back off from her support - was instrumental in killing the deal. Nancy Pelosi, too, was an enabler, allowing Neal to kill the bill. She was heard assuring industry representatives that "we are not going to give a handout to big insurance companies."

As journalist Jon Walker tweeted:

Disgraceful. @SpeakerPelosi is going around trying to keep your premiums sky high to pay off private equity firms and bad actor hospitals.

Everything about the spiking of the deal indicates that money talks, and loudly, with large donations having been made to Schumer’s Senate Majority PAC by the Greater New York Hospital Association and with donations too to Richard Neal from private equity.

And so the legislation is dead until and unless Schumer and Neal can get their preferred (and price-raising) approach adopted. Meantime, real people are suffering from getting huge bills they have no control over. As Elizabeth Rosenthal observed recently, practices that are both routine and legal in the medical industry are nonetheless in essence fraudulent. The business model of U.S. medicine is fraud – and a very profitable business model it is.

NOTE 1: Although a number of states have passed surprise bill legislation, it is critical to get something passed on a federal level, because most large employer-based plans are federally regulated and state laws don’t apply.

NOTE 2: Benchmarking and arbitration are not the only possible approaches. Another suggestion is to abolish the practice of separate bills from doctors for services provided in hospitals.

Private and Commercial Interests Raise More Dander, but Here's a Salve

What raises more of our dander in these pages than anything else? Recent posts, occasionally mine but especially those from FIRM's President and blogueur extraordinaire Roy Poses MD, suggest the answer's a no-brainer: shareholder-favored large-scale commercial interests in health care. Not even creeping disruption. Galloping. So much so, maybe the take-over's now complete and fold our tents. But wait. Turns out there's a sure "what if" in that statement, in a newly appeared book. I'll come to that in due course.

For those of us who pay attention enough to write about it, this blog's subject--worrisome departures from integrity and responsibility in medicine--has converged with the larger issues roiling American society at large, becoming one and the same. In recent years that convergence has become an increasingly persistent and central topic of private discussion for our bloggers.

Just look at two of the recent subjects on which Poses has focused. I'd written a bit about the demise of Hahnemann and fading of its owner Tenet a while back. Now Dr Poses has just gone back there to decry the use of that hospital's residency program as another commercial pawn in the institutional bankruptcy game. Why did a bankruptcy judge let this happen? Well, you can read the post, but essentially it was a variant on the too-big-to-fail argument, too much money at stake.

Whose money? Why, of course, private equity's, and for the hell of it let's add hedge funds'. Behind so many events in the private and especially the public sectors--add in K Street's and lobbyists' doleful effects--loom these investors who must at all costs be protected at everyone else's expense. No different than with rapacious banks a decade earlier: "when the music's playing, you have to get up and dance." (Chuck Prince, Citigroup.)

So throw the hapless young docs under the bus. (And a lot at Hahnemann are FMGs: so why not say the hell with them?!?) To see such young trainee physicians, USMGs as well as FMGs, all of whom uproot themselves and devote scores of extra hours weekly to obtain certification, on an auction block like enslaved bodies--this is a pitiful and egregious sight. Yet there's a certain ugly logic to it, which will only start to change when corporate actors in their planning start to consider more than investors. But wait again! That's maybe already started to happen! In a recent leader, in no less than that left wing (not) rag The Economist, an editorialist usefully and eloquently ponders "what companies are for."

The leader writer argues that companies need, and not out of altruism, "to adapt to society's changing preferences." A decline in firms' ethics and the inevitable counter-reaction combine to push for a major shift, which may in fact already be under way, away from interpreting the 19th century Anglo-French introduction of limited liability as license to privilege the investor above workers and other stake-holders. And who cares if this is premonitory self-cleansing? Health care needs such a readjustment, above almost every other sphere with the probable exception of the need for blunting climate change.

And meanwhile the private equity beat goes on: despite overwhelming support for a curb on "surprise medical billing," Dr. Poses reports still more recently, private equity hides behind white coats, who are either powerless, complicit, or both. Here the white coats are employed specialist groups, backed by corporate entities, opposing a more rational approach to the reimbursement of emergency costs. Radiology and emergency medicine are particularly susceptible to this sort of manipulation, and ought to be equally susceptible to rational planning. Those specialties, being quite remunerative, won't just empty out because someone came in and capped or arbitrated their charges.

Here the problem is a lot like pharmaceutical costs, where increasingly rationality flies out the window when the profit motive runs amok. In some ways PhRMA is in fact even more retrograde, with some notable (mostly non-US) exceptions, than ER staffing companies or for-profit hospitals. The sky's the limit both for price increases and the alibis (research!) used to justify them.

The Economist leader draws to a conclusion by citing bigness and lack of accountability as the real roots of these organizations' problems They point out that large scale and anti-competitive motives are exacerbated by the rise of the digital economy, and argue that effective government's needed to counter such trends and restore competition. Amen. (Or just read any major newspaper of late--same anticipatory kumbaya pronouncements from an awful corporate leadership.) Praise the Lord and pass the ammunition.

But another sort of amen, and a comparative international view of some of these challenges, recently came across my desk in a new book that may have escaped some in this blog's readership. After some late-60s and '70s studies at Harvard and Mount Sinai, physician and New York native Susan Levenstein moved to Rome. She's been there ever since and now emerges as today's most prominent, and probably most eloquent, expatriate practitioner. Levenstein seems to've stuck out her overseas gig for both personal and ideological reasons, admiring the equal-access and public-health features of the Italian health system.

In her book Dottoressa, a new memoir from the estimable publishing house Paul Dry Books, Levenstein spares no criticism of what she sees as that system's flaws, observed over more than four decades of practice in the Eternal City. (I furnish the first link above, Amazon's, for its several useful reviews.)  Replete with rich anecdote--some of her Roman clerics and college-abroad students will stick with me forever--Dottoressa gives us lots of information on what makes the Italian health system one this next wave of US health policy wonks ought to take a look at.

Not that Italy does it all right. The public system's chronically underfunded, she freely admits. (Indeed she was forced early on to shunt her own practice mostly to the private realm because of classic bureaucracy and nepotism.) But in key areas including urgent care (free) and access to medication (cheap), she points out how they get it right. She notes that National Health's attempts to claim some cause-and-effect between public access and the nation's vaunted longevity is rather suspect. She points instead to nutrition, ample time for relaxation and stress relief, and the social compact, as reasons for Italy's number-two (after France) rating for health in the EU.

I hope at some point to have a conversation with this author. But I haven't yet. So I'm not sure whether she'd consider it a direct extension, or something of an extrapolation from her arguments, to suggest the message of Dottoressa could be particularly useful to those engaging in current Democratic Party circular-firing-squad discussions around health care. Italy has a lot that's good about privately funded care. And in complementary fashion, it has a lot that's good about the public side. The key variables are--in a lot of ways like Switzerland--the universality of coverage and the availability of some robust government controls on key costs. Current US proposals to eliminate private insurance don't play in in either country, and the heterogeneity is seen by many as a net good.

Levenstein's new book is therefore a tonic for general readers. (I'll not dwell on the delicious speziatura of her personal story as a New York Jew serving patients in a Catholic country, not to mention tending to the embassy set.) But it should particularly be read by those among the policy army advising Democratic candidates on matters of health.

It's amazing to imagine a government, despite its own extreme dysfunction in so many realms, still managing to keep health care accessible. It helps that (to use one piccante example) an anal-pinworm medicine in Italy costs the patient what it actually costs to make--maybe a euro--with perhaps un po' of profit. Not the hundred-plus-fold multiplier to which some private equity investors leaned on the CEO to jack the US price.

At least in its northern half (many southerners choose to travel north to get what they perceive as optimal care), Italy, like Switzerland, does not suffer from more primitive care in its major referral centers. With provincial referral regionalization and a robust ambulance service (now fully equipped thanks to the EU and charity), one can observe extraordinary results despite the bilge that lobbyists in the US choose to disseminate about "socialized medicine."

This system, in its public hospitals, is vastly admired by the best and brightest of US physicians, including surgeons and cardiologists. Coronary patients were getting radial-artery catheterization routinely before we were. Emergency neurology and other specialized attending consultants in Italian public hospital ERs have rotated through the best services in the US and elsewhere in the world, including of course Italy itself.

Our public hospitals mostly withered on the vine a long time ago. So let's not go overboard criticizing an Italian one that's low on bathroom paper towels.

Why do these physicians, those who train partly abroad come back to Italy to live? They could stay in the US and make the big bucks. Well, some admittedly don't come back. But most do--and why? Go back and re-read the paragraph above that starts "not that Italy does it all right."

Bottom line: Italy does an awful lot right right now. It's likely to improve further with ongoing EU standardization.  In the US, right now, we don't do enough right. That's pretty scandalous, especially since today's Congress has so many physicians in it. But for sure, some of that lot seem to've forgotten their professional roots.

The New (Ab)normal in Health Care Dysfunction

Introduction: The Issues Ignored by Discusisons of Health Care Reform

After the failed attempt to "repeal and replace" the Affordable Care Act (ACA, Obamacare) in 2017, we summarized what we thought were the main issues that traditional discussions of health care reform in the US (and sometimes in other countries) did not address.Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care.  The ACA notably seems to have improved access, but hardly addressed cost or quality.

Now, in 2019, these issues also seem to only be getting more so.  So a little more than two years into the Trump regime, I thought we should assess the new (ab)normal in health care dysfunction, trying as best as possible to use the framework from our 2017 summary, with examples from our blog posts.


Distortion of Health Care Regulation and Policy Making: the Rise of the Incoming Revolving Door

We had previously noted that companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.  Up to the Trump era, nearly all those cases involved people who left government who were offered corporate positions in firms that might have been affected by regulations or policies influenced by the government agencies for which they formally worked, the outgoing revolving door.

However, in the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers.


- We noted a stealth marketer for health care corporations becoming a key Trump economic adviser (look here)

- We found numerous more examples in October, 2017, including two people from the same lobbying firm, Greenberg Traurig Alston & Bird, which that year had  "earned more than $4.4 million lobbying so far this year for health care companies and trade groups including Novartis AG, Verax Biomedical, the American Hospital Association, St. Jude Children’s Research Hospital, and Aetna....," given top Department of Health and Human Services (DHHS) positions.

- A little later that month, we noted that one of those two former lobbyists, Mr Eric D Hargan, had become acting Secretary of DHHS (look here).

- Slightly later that month, there was an even more striking example, the new (permanent) Secretary of DHHS, Mr Alex Azar, who replaced Mr Hargan, was a former top executive of pharmaceutical company Eli Lilly.

- In November, 2017, an advocate for the discredited former CEO of UnitedHealth become an Assistant Secretary of DHHS. 

-  Later in November, we found two more examples of the incoming revolving door, including a lobbyist for pharma/ biotech company Gilear becoming director of health programs for the Office of Management and the Budget (OMB) here.

- In March, 2018, we posted a long list of industry figures, including a slew of lobbyists appointed to DHHS leadership positions.

- in April, 2018, we posted the next list, of top industry executives going to major executive branch positions.  The most striking example was a vice president at CVS, formerly at Pfizer, becoming a senior advisor to the Secretary of DHHS (who is a former Eli Lilly executive) for drug price reform. Pfizer and Eli Lilly alumni in charge of drug price reform, what could possibly go wrong?

- In July, 2018, the next list included a senior advisor at again Eli Lilly appointed to head an FDA division.

- In February, 2019, the list included a person with multiple leadership positions in for-profit health insurance companies, including WellPoint, and most recently a Medicaid managed care insurance provider, appointed to lead "health care reform" for DHHS.  Again, from the insurance industry to lead health care reform, what could possibly go wrong.

- In March, 2019, we noted that the newly appointed acting director of the FDA had founded and/ or was on boards of directors of multiple biotech companies.

This was a staggering record of managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door, which some have already asserted should be regarded as not merely severe conflicts of interest, but of corruption.  

Distortion of Health Care Regulation and Policy Making: Stealth Policy and Advocacy Morphing into Propaganda and Disinformation, Now may be Orchestrated by a Hostile Foreign Power

We had previously noted that promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.  Now this information may be connected to, or even organized by a hostile foreign power  

In March, 2018, based on revelations of what appeared to be an organized disinformation effort engineered by Cambridge Analytica and associates, using large amounts of personal data liberated from Facebook, to promote the Trump campaign, we started to ask how we could address deceptive public relations, propaganda, and disinformation in health care under a regime that had so benefited from foreign based disinformation efforts?

In April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak, and possibly for some of the unsupported assertions made about measles and measles vaccinationa by government leaders (see below).  The Soviet Union, which of course then included Russia, had orchestrated a disinformation campaign about HIV in the 1980s.  Erroneous beliefs generated by this campaign persist to this day.  The USSR had a principle role in the development of disinformation and other active measures meant to destablize western democracies.

 As recently documented in the redacted version of the Mueller report, Russia launched a disinformation campaign to swing the election to its preferred candidate, Donald Trump.  The role of a hostile foreign power which had used active measures during the election also using active measures to spread disinformation about medicine and public health should not be dismissed. 


Bad Leadership and Governance: Ill-Informed Leadership Now Approaching Flagrant Ignorance While Eschewing Expertise

We have long decried leaders of big health care organizations who seemed to have little background in or knowledge of biology, medicine, health care, or public health.  Typically, these were leaders of big health care corporations, such as pharma/device/ biotech companies, health insurance companies, hospitals and hospital systems, etc who were trained in management, and thus could be called managerialists.  

However, during the Trump regime we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics.  We had not previously expected leaders of government to be personally knoweldgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Since the Trump regime began, perhaps inspired by examples from Trump himself, various political/ government leaders began to publicly say ignorant or downright stupid things about such topics.

-  For example, in September, 2017, we noted a series of examples showing some basic ignorance of health policy, including fundamental confusion about the nature of health insurance.

- In August, 2018, we noted that Trump had long been an apologist for asbestos, which is known to cause asbestosis, lung cancer, and mesothelioma, claiming that those opposing use of asbestos were associated with organized crime, while more recently Trump's EPA seemed willing to relax regulation of asbestos, at a time when Russia seemed ready to become the major US supplier of it.

Bad Leadership and Governance: From Incompetence (in the Colloquial Sense) to Cognitively Impaired or Demented Leadership

Again, previously we had discussed  ill-informed and incompetent leadership in terms of leaders who had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.

However, we began to note concerning examples suggesting that the top leader of the US executive branch, President Trump himself, could be cognitively impaired perhaps from a dementing, neurological or psychiatric disorder.

- In October, 2017, we first started cataloging pronouncements by President Trump on health care and related topics that started with a grossly cavlier attitude toward health policy (e.g., it is only about fixing somebody's back or their knee or something," and ended with word salad:

Well, I’ve — I have looked at it very, very strongly. And pretty much, we can do almost what they’re getting. I — I think he is a tremendous person. I don’t know Sen. Murray. I hear very, very good things.

I know that Lamar Alexander’s a fine man, and he is really in there to do good for the people. We can do pretty much what we have to do without, you know, the secretary has tremendous leeway in the — under the Obama plans. One of the things that they did, because they were so messed up, they had no choice but to give the secretary leeway because they knew he’d have to be — he or she would have to be changing all the time.

And we can pretty much do whatever we have to do just the way it is. So this was going to be temporary, prior to repeal and replace. We’re going to repeal and replace Obamacare.

As we were taught in medical school, word salads may be produced by patients with severe neurological or psychiatric disorders.


- In January, 2018, we discussed more examples of Trump's confused, incoherent comments on health care.

- In May, 2018, we noted attempts by Trump Organization functionaries to intimidate Trump's former personal physician, presumably to prevent him from revealing details of the president's medical history.

- In December, 2018, we cataloged Trump's counter-factual, and often severely incoherent pronouncements - basically more examples of word salad - about public health, health care and other topics, at times interspersed with claims of his high intelligence.

Health care led by people with business or legal training who are willing to get advice from health care, public health and medical specialists may be as good as it gets.  Health care led by such people who do not consult experts if worrying.  Health care led by people who report to a cognitively impaired, demented or psychotic leader is extremely worrying (as is government with such leadership.)

Bad Leadership and Governance: Mission-Hostile Management Now Driven Less by Pecuniary Considerations, More by Ideology, Partisanship, and Religious Sectarianism

We had previously noted that health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values.  The example we cited then was a hospital CEO who allegedly over-ruled medical leadership to hire a surgeon despite reports that his patients died more frequently than expected, gamed reports of clinic utilization, and associated with organized crime (look here).  Most such examples seemed to be generated by leaders who put their organization's revenue, often in parallel with their own compensation ahead of patients' and the public's health.

We also began seeing examples of how politically appointed officials of health related government agencies who had no experience or expertise in health care or related fields began to assert control over health care professionals in the agencies to facilitate the Trump regime's political agenda apparently regardless of the effects on health. Sometimes the problem seemed to carry over from the leaders' previous management, rather than medical, health care or public health experience.  For example, in February, 2018, we noted that the physician who was Secretary of the Veterans Administration was challenged by a political a political appointee who used to run a brewery.

However, we then began noting leaders who also lacked medical, health care or public health background or expertise whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health.


- In April, 2018, we noted a host of appointments of people who flagrantly lacked any health care or public health related experience or expertise to leadership positions in government agencies whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health. For example, a 23-year old whose only experience after college was in Trump's campaign was given a significant position in the Office of National Drug Control.

- In April, 2018, we posted another such list, including a blogger who promoted racism and conspiracy theories given the Deputy Directorship of Communications for DHHS.

- In July, 2018, we noted the appointment of a physician to a leadership position in family planning within the DHHS who cited "facts" completely unsupported by evidence to justify religiously based health care policies, e.g., using her argument that adopting a child is like a "second death" to argue that mothers should not give their children up for adoption.

- In August, 2018, we discussed  three political appointees to DHHS, none of whom had any health care or public health related experience or expertise, all of whom made pointedly political public comments after their appointments, from deriding their political opponents as "clueless" and "crazy"to alleging Hillary Clinton arranged a murder.

 - In November, 2018, we noted pronouncements about health care or public health by federal agencies under the Trump regime, right-wing politicias who back Trump, and propagandists who back Trump which were unsupported by evidence, but seemed designed to support right-wing ideology or sectarian religious belief.  These included assertions that immigrants and asylums seekers carried infectious disease, that intersex patients do not exist, that contraception causes cancer and violent death, that pornography is a major public health hazard, etc.

- In March, 2019, our list included examples of multiple leaders at the state level, all Republicans, including the Kentucky Governor asserting that zombie television shows cause mass shootings, but exposure to extreme cold does not harm schoolchildren; and numerous unsupported pronouncements by state legislators about measles, including the Texas state representative who stated antibiotics can treat measles.

- In April, 2019, we discussed another batch of bizarre statements about the measles and vaccination policy made by President Trump, again the Republican Governor of Kentucky, and various Republican state legislators.  

Again, basing health care and public health decisions primarily on money seems likely to be bad for patients' and the public's health, but basing them purely on political ideology or religious belief seems worse. In some cases, the resulting mission-hostility seems to translate into violations of the US constitution.  For example, making health care decisions based on a particular religion's beliefs could be harmful for patients or citizens who do not share these beliefs, plus violate the Constitution's guarantee of freedom of a government establishment of religion.

Bad Leadership and Governance: Mission-Hostile Management by Now Partisan Corporate Leadership  

Again, previously the mission-hostile management we noted at the corporate level seemed mainly driven by pecuniary concerns, putting corporate revenues and resulting management compensation ahead of patients' and the public's health.  However,we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues.

- In June, 2018, we first noted how a large health care corporation, the huge pharmacy chain CVS, had been secretly making contributions to an ostensibly non-profit organization which actually served solely to promote Trump regime policies, including some that seemed to subvert claims the corporation had made about social responsibilty.  The contributions themselves seemed to conflict with the corporation's charitable giving policies.

- In September, 2018, we noted that big health care corporations often make high-minded public pledges about supporting patients' and the public's health, and sometimes social responsibility, but have been found to be covertly supporting policy initiatives that seemed to subvert these goals, using "dark money."  The dark money groups they used to channel this money often had explicitly partisan leadership and direction, usually right-wing and Republican.

 - In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates.

- In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians.

- In March, 2019, we noted a Transparency International study of policies on political engagement of multinational pharmaceutical companies, all of which operate in the US.  Only one disavowed the revolving door, and only two eschewed direct corporate political contributions.

- Also, in March, 2019, we discussed a study of the personal political contributions of CEOs of large corporations.  In the 21st century, the CEOs' contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party.

This suggests yet another route towards government putting ideology and partisanship ahead of patients' and the public's health.


Bad Leadership and Governance: Conflicted, Corrupt Corporate Leaders Now in the Context of Flagrant Conflicts of Interest and Corruption at the Highest Levels of the US Government

We had previously discussed numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.  One would hardly expect corrupt leadership to put patients' and the public's health ahead of the leaders' ongoing enrichment.

Prior to July, 2017, we had discussed some particular cases in which Donald Trump and his family had been involved in ethically questionable activities prior to his becoming president.  However, by  August, 2017, we started to discuss the corruption at the top of the regime. 


- In January, 2018, we first discussed the accumulating evidence of pervasive corruption at the top of the US executive branch, based on articles in the media, and the launch of a website devoted to tracking such corruption.

- In July, 2018, we summarized new sources of evidence about top level government corruption.

- In October, 2018, we posted yet another update, including summarizing a new and very lengthy report about the scope of Trump and associates' conflicts of interest and corruption, which at the time required 26 pages to print. It documented multiple ongoing instances of the Trump Organization, whose biggest owner is Trump, receiving large ongoing payments from foreign governments, the US government, and state governments.  The former payments seemed to explicitly violate the "foreign emoluments clause" of the US  Constitution, which bans presidential conflicts of interst involving foreign governments, and the "domestic emoluments clause," which bans those involving the federal and state governments.

- In October, 2018, we discussed the latest advances in understanding of global corruption, via Tranparency International's global meeting, which included description of trans-national kleptocratic networks, which now seems to describe Trump and the Trump Organization.

- In April, 2019, we posted our latest discussion of pervasive high-level corruption, which referenced updates from sources mentioned earlier, plus three new sources.

Prior to the Trump regime we had criticized law enforcement for a lack of interest in vigorously prosecuting health care corruption.  We documented numerous examples of the impunity of top health care corporate executives who almost always escaped any negative personal consequences even when their organizations paid large fines for bribery, kickbacks, fraud and the like.  We often attributed this laxity to excessive sensitivity respect of the value of these corporations and their products.  However, the potential for encouraging health care (and other kinds of) corruption under a regime that is itself frankly corrupt is mind boggling.

[picture of Trump International Hotel in Washington, which is frequently patronized by foreign government officials, whose payments to Trump via the Trump Organization appear to amount to the "foreign emoluments" prohibited by the US Constitution.]

Overarching Issue: Taboos Previously Enabled by Private Organizational Behavior, Now by Government Agencies and Officials, Despite the First Amendment

When we started Health Care Renewal, such issues as suppression and manipulation of research, and health care professionals' conflicts of interests rarely appeared in the media or in medical and health care scholarly literature.  While these issues are now more often publicly discussed, most of the other topics listed above still rarely appear in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant.  For example, a survey by Transparency International showed that 43% of US resondents thought that American health care is corrupt.  It was covered by this blog, but not by any major US media outlet or medical or health care journal.  We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  As we noted above, the people who profit the most, those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.  But, if we cannot even discuss what is really wrong with health care, how are we going to fix it?

Since the beginning of the Trump administration,  we began to note more examples of government officials under Trump attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control.

- In September, 2017, we noted an attempt for Trump political appointees to blockade information released from the Department of Health and Human Services (DHHS) that the regime found offensive.

- In February, 2018, we noted attempts by a consultant for the Center for Medicare and Medicaid Services (CMS), a major component of DHHS, to intimidate a health care journalist.

- In April, 2018, it became apparent that the head of CMS has directed millions in contracts to a Republican public relations firm, partly to burnish her image, and that firm had hired the consultant noted above.

- We also found attempts to squelch attempts by current or former government workers to criticize Trump and his policies.  In August, 2018, we noted Trump had White House staffers sign non-disclosure agreements, which seems to expressly violate first amendment protections of free speech and federal law.

Given how hard it was to reverse the anechoic effect in the past, how much harder will it be to open discussion of what is really wrong with health care when the power of the US government is used to censor ideas which the regime dislikes?


Discussion

For years, I thought that health care dysfunction was primarily about individuals and private organizations, including but not limited to pharmaceutical, biotechnology and device companies; hospitals and hospital systems; insurance companies, academic medical institutions; physicians and their practices; etc, etc, etc.  Consequently, I thought these individuals and organizations needed better awareness of health care dysfunction to provoke them to improve matters.  I thought of the government as being involved, but mainly because of well-intentioned, sometimes bumbling government actions and policies that often had unintended effects, and sometimes excess coziness with the health care industry.  While I knew that the government was subject to regulatory capture and various leadership problems, its role, at least in the US, seemed almost secondary.

But in the Trump era, there is a new (ab)normal.  All the trends we have seen since our last discussion of health care reform are towards tremendous government dysfunction, some of it overtly malignant, especially in terms of corruption of government leadership of unprecedented scope and at the highest levels, and overt influence of government-favored political ideology and religious beliefs on health care policy and other policies and actions.

I hope that the above attempt to summarize these new trends will urgently point health care and public health professionals, patients, and all citizens towards a much more vigorous response.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who? 



        

Another Missing Link Discovered: 1969 IRS Rule Change Allowed US Hospitals to Discriminate Among Patients Based on Ability to Pay

Prelude: the Suits in the Elevator

Another long night on call of my interniship was over.  Having managed to wolf down breakfast and brush my teeth, disheveled and in unwashed scrubs I stumbled into the elevator on my way to the wards.  In it were some of well-groomed people in nice suits.  They looked at me with wrinkled noses, oozing disdain.  I wondered who they were: pharmaceutical representatives?  Somewhat troubled, I disembarked the elevator and went to work, just another house-staff cog in the teaching hospital patient care machine.  The suits went up to the management floor.  Later I would learn they were top hospital executives....

Introduction: the Rise of Health Care Dysfunction

Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care, but reform efforts have yielded little improvement.  (For example, recently the Accessible Care Act seems to have improved access, but hardly addressed cost or quality.)

In the early 2000s, before we started Health Care Renewal,  we encountered lots of disgruntled health care professionals who thought that health care was going off the rails, but had no idea what to do about it.  Some crude qualitative interviews, and a lot of delving into news stories about health care dysfunction suggested a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  They included threats to the integrity of the clinical data base, including manipulation and suppression of clinical research; deceptive marketing; distortion of health care regulation and policy making; bad leadership and governance; concentration of power, abandonment of health care as a calling, perverse incentives putting money ahead of patient care, teaching, and research; the cult of leadership; managerialism; impunity enabling corruption; and taboos preventing honest discussion. (Look here for details.)

As a medical student, I was idealistic, thinking it was all about taking care of patients in a humane way, based on science. Was I just completely naive?  Others, however, have described health care in the US from the end of World War II into the 1960s as underfunded, but earnest in pursuit of the mission.  It was also a very human affair, not based in large organizations and big business.  Physicians practiced as individuals or in small groups.  Hospitals were local, community-based charitable organizations or teaching hospitals tied to single medical schools.  Insurance was largely provided by regional non-profit organizations or the government. 

We seem to have stumbled down a dark path since those days. Now everything revolves around huge hospital systems and for-profit corporations.  Physicians are now largely corporate employees.  It is all about money.  And we have the most most expensive health care system in world.  How did we get from there to here?

Early on, many of the people we met seemed to insist that it was all inevitable.  Some changes admittedly were not too hard to explain.  For example, after government started providing insurance to the elderly and poor, and research spending ramped up, costs rose, and in the Nixon administration the government outsourced cost control to commercial managed care.  By the 1980s, as Ludmerer wrote in Time to Heal (p 365), under pressure from managed care:

The field of hospital administration became more tightly affiliated with programs of business administration, and hospital administrators increasingly held M.B.A. degrees.  The new hospital administrators assuemed business titles (president or chief executive officer rather than superintendent or director), demanded and received corporate levels of compensation, and retained hordes of management consultants....

Now I could recognize those suits in the elevator.

However, the roots of the huge changes that happened in the US from the end of World War II to now were frequently unexplained.  Why could not business oriented management still put patients first? Why were the new managers so ill-informed, ignorant of or even hostile to the health care mission, self-interested, conflicted or even corrupt? Why did regulation of health care seem so big, yet so ineffectual?  Why were the prices of some goods and services so far beyond any value that they could have provided?  Etc, etc, etc.

Since the early 2000s, we have learned more about the historyof health care dysfunction, and also stumbled upon some missing links that added to the explanation. 

For example, we have discussed:
- how market fundamentalist lawyers challenged the power of medical associations to enforce medical ethics, allowing the commercialization of medical practice (look here)
- how government failure to enforce the responsible corporate officer doctrine allowed the impunity of health care corporate management (look here)
- how an obscure AMA committee (Resource Based Relative Value Scale Update Committee, or RUC) took control of the government process for setting physician payments, hugely favoring payments for procedures and invasive treatments.

This week, we found another missing link.

An Obscure IRS Rule that Allowed Hospitals to Discriminate Among Patients According to Ability to Pay

On March 5, StatNews published a commentary by Patrick Masseo entitled "IRS Rule Changes Helped Create a Payment-Focused Hospital System."  It noted

Often overlooked are small regulatory changes, such as adjustments to Internal Revenue Service codes over the past 70 years, that have allowed hospital care to evolve from a charitable mission into a profit-driven industry.

The historical background is

In 1956, as hospitals were evolving into centers for medical interventions, the Internal Revenue Service issued Revenue Ruling 56-185, which applied solely to hospitals. This ruling was the first to allow hospitals to qualify for federal tax exemptions if they fulfilled qualifications related to providing health care. That represented a deviation from the previous requirement of affiliation with a religious institution or fulfilling another charitable purpose.

Revenue Ruling 56-185 established four criteria that a hospital must fulfill to qualify for 501(c)(3) tax-exempt status:

- be organized as a nonprofit charitable organization for the purpose of operating a hospital for the care of the sick

- be operated to the extent of its financial ability for those not able to pay for the services rendered and not exclusively for those who are able and expected to pay

- not restrict the use of its facilities to a particular group of physicians and surgeons, such as a medical partnership or association

- net earnings must not benefit directly or indirectly any private stakeholder or individual

Through criteria 2 of Revenue Ruling 56-185, the IRS — not the legislative, executive, or judicial branches of government — mandated that tax-exempt hospitals must provide care to patients who were unable to pay without an expectation of payment.

 However, for reasons that remain unclear,

  

In 1969, the IRS issued Revenue Ruling 69-545, which updated the federal tax exemption requirements for hospitals. This ambiguous ruling, written as a case example rather than a defined list, included a subtle change of language that permitted tax-exempt hospitals to restrict access to care depending on a person’s ability to pay. For many individuals, that meant their health insurance status. According to Revenue Ruling 69-545, a hospital that operates as described as follows (emphasis added) would qualify:

The hospital operates a full time emergency room and no one requiring emergency care is denied treatment. The hospital otherwise ordinarily limits admissions to those who can pay the cost of their hospitalization, either themselves, or through private health insurance, or with the aid of public programs such as Medicare. Patients who cannot meet the financial requirements for admission are ordinarily referred to another hospital in the community that does serve indigent patients.

This language is a subtle yet monumental contradiction of the IRS’s original 1956 guidance, which stated that a 501(c)(3) hospital 'must not, however, refuse to accept patients in need of hospital care who cannot pay for services.'

Revenue Ruling 69-545 was neither an act of Congress nor a flashy executive order, yet it laid the foundation for the U.S. health care system to become driven by payment, a privilege of the rich and a necessity continually out of reach for the poor.

There was almost no public discussion of its change and its implications

The year after this ruling appeared, The Tax Lawyer, a publication of the American Bar Association, described the 1969 rule change as 'representing a shift by the [Internal Revenue] Service from requiring the admission of a substantial number of charitable cases in order to qualify for exempt status.'

A 1971 paper written by Marilyn G. Rose for the Catholic University Law Review correctly forecast the implications of this new ruling. 'Most importantly, this tax policy [Revenue Ruling 69-545] operates as unwise health policy by perpetuating and enlarging the gulf between the health care available to the rich and that available to the poor,' Rose wrote.

Beyond those publications, I found little evidence of journalistic coverage of the 1969 rule change. Only a handful of academic papers on it were published between the 1970s and the 1990s.

New IRS rulings have not substantially changed the effects of the 1969 ruling.  Since 1969, but especially in the last 30 years, we have seen increasing evidence of hospital leaders' hostility to the traditional mission that put patient care ahead of all else, including revenue generation.  Instead, even in non-profit institutions, leaders have appeared to adopt the shareholder value dogma propogated by business schools, putting revenue ahead of all else (look here).  Of course, as revenue goes up, hospital management has been able to command even greater compensation.  When revenue generation is the main goal, perverse incentives drive ignorance, conflicts of interest, even crime and corruption.

And yet it took 50 years to discover this missing link.

And it raises further questions.  Who was responsible for the 1969 regulatory change?  What was the motivation for it?  Why did it attract so little attention at the time?  Why did nobody really notice it for 50 years?
 
Discussion

Those who are ignorant of history... are unlikely to be able to fully challenge its effects.

As we learn more about the hidden history that explains where we are today, a bigger meta-question is why there has been so little curiosity about the roots of our current health care (and broader political economic) dysfunction, at least until now.

When people do not look to answer questions, it  may be that they fear what they will find.  

While we try to push for all the reforms that are so badly neeed, we are handicapped by our ignorance about how our current troubles came to be.  We must vigorously seek reform while simultaneously vigorously investigating why the world went wrong. 

How Stupid Do They Think We Are? - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

In the early 21st century, the debate about health care reform in the US ramped up.  The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients.  Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare.  Arguably, Obamacare ended up damaged but not repealed.  Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect.  (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US.  Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense. 

Dark Money to Defend Commercial Health Insurance

We already discussed  how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats.  They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board.  We listed 10 such members in 2015.   It also historically has received financial support from some corporations.  We listed 17 in 2018.


Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All."  The Hill stated its

members include major industry players such as America’s Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America

So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible.  Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new.  What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies.  Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison) 

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

'Most people don’t understand the basics of health-care economics in the United States,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland....

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him.  Thus, he began with an implied logical fallacy, the appeal to authority.

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred.  $3.5 trillion? Health care costs paid by employers and employees?

The context of  his use of that phrase did not help.  Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS).  However, that was total health spending, not just the amount spent by Medicare and Medicaid.  Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees.  While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.


Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point.  So in formal terms, he used the logical fallacy of an argument by gibberish.

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. 'I don’t think [corporations and employees] can afford to provide that access as described.'

However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described."  So this appeared to be an example of the logical fallacy of the non-sequitur.

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News.  So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate.  One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy. 

First, from the New York Times, January 29, 2019:

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You’re talking about trillions of dollars,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation’s first primary in 2020.

'I think you can have ‘Medicare for all’ for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time.'

Second, from CNN on January 30, 2019:

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. 'It's unaffordable.'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much.  Yet neither addressed how much our current health care system costs.  However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system — and that journalists almost never do when they’re asking questions. You have to compare what a universal system would cost to what we’re paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That’s a lot of money. But you can’t understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we’ll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years — which every universal plan does — you can’t say it’s 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison.

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen — whose understanding of investments, costs and benefits helped them become billionaires — can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they’re not biases at all but are instead inescapable rationality.

Maybe.  However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.  

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That’s not correct. That’s not American,' Schultz said on CBS. 'What’s next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised.  Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition. 

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry.  But that is for another day....

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit  insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money.  We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.


It is hard to believe that the defenders of the current system are not mostly self-interested.  That status quo has made some people very rich.  

It is also hard to believe they are stupid.  However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote,

Wendell Potter, author of Deadly Spin, has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers.  He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering.  He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work.  Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal.  Still, however, their arguments are ultimately built on sand.

As I did in 2011, it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake, from climate change to defense policy.
[Potter, Huffington Post]

So,

The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical.
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.

ADDENDUM (22 February, 2019) - This post was re-posted on Naked Capitalism.  See the comments section for a quite interesting discusison. 

Return of the Anechoic Effect - Rest in Peace, Health Wonk Review

Introduction: Blogging About Taboo Topics in Health Care

We started Health Care Renewal in 2004 to discuss the causes of health care dysfunction that rarely were mentioned in polite conversation at the time.  When we started Health Care Renewal, such issues as suppression and manipulation of research, and health care professionals' conflicts of interests rarely appeared in the media or in medical and health care scholarly literature.  While these issues are now more often publicly discussed, many other topics, such as  deceptive marketing of health care products and services; distortion of health care regulation and policy making through propaganda and disinformation,  regulatory capture, and the revolving door; ill-informed. mission-hostile, conflicted  corrupt or criminal leadership; etc, etc, etc; still rarely appear in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant (see this post).  For example, a survey by Transparency International showed that 43% of US resondents thought that American health care is corrupt.  It was covered by this blog, but not by any major US media outlet or medical or health care journal.  We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  As we noted above, the people who profit the most, those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.  But, if we cannot even discuss what is really wrong with health care, how are we going to fix it?

In the early 2000s, new internet based platforms appeared that allowed us and others to publish facts and opinions about health care dysfunction that otherwise were taboo.

The Darkness Gathers

Unfortunately, now the world of incisive medical and health care policy discussion is contracting again. Health Wonk Review, a compendium of the best blogging in health care policy, is closing down.  The email from its founders and blog-meisters read:

After a baker’s dozen years  and more than 280 issues, we’ve decided to call it a day.

It’s become a bit more of a heavy lift to get varied hosts.

We moved to a monthly issue to address that, but it’s still been slow going.

Submissions are down too as more people abandon blogs in favor of social channels like Twitter and LinkedIn.

Readership and cross posting appears to have waned, too. 

Going forward, we may host an ad hoc issue occasionally under the HWR banner and invite your participation when health policy issues rise to the surface, but the regular issues will cease.

So it joins the many medical and health care blogs I used to follow to help learn about what was really going on in health care, including items that it was considered impolite to discuss too loudly, lest they offend the powers that be. Some worthy blogs now gone are,  in alphabetical order:

1BoringOldMan - since 2017, after the death of its revered blogger, Dr Mickey Nardo

Carlat Psychiatry Blog - 2017, by Dr Daniel Carlat

HealthBeat - 2015, by journalist Maggie Mahar

HealthNewsReview - 2018, by journalist Gary Schwitzer

Hooked: Ethics, Medicine and Pharma - 2014, by Dr Howard Brody

Not Running a Hospital - 2016, by former hospital CEO Paul Levy

PharmaGossip - 2016, by an anonymous blogger

Scientific Misconduct Blog - 2010, by Dr Aubrey Blumsohn

Side Effects- by journalist Alison Bass

Note that the content of blogs with links above is still available, but the bloggers are not posting any more.

What Next?

Blogs, which were seen as a big innovation in the early 2000s, now of course seem a bit old fashioned and stuffy only a few years later.  However, blogs then served an important purpose.  They provided publication platforms which were immediate, and not subject to external editing, publication delays, or the worries of publishers' attorneys or corporate leaders.

Many of us went to blogging to discuss anechoic issues because it was so difficult to inject these discussions into the media, or medical or health care scholarly publications, at least without long delays, and editing that was not always helpful, and at times took not only the edge off, but much of the content as well. 

However, as the leaders of Health Wonk Review indicated above, social media is now all the rage. But social media has weaknesses, and social media platforms may not replace blogs.

Blogs can be as immediate as Twitter, for example (and I confess I do have a Twitter feed.)  But they allow longer form posts that can include nuance, complex arguments, analytic approaches, etc.  Anyone can read most blogs.  They do not push people to identify as followers.  They do not necessarily come with advertisements, with atttempts to profile readers for marketing purposes. They do not only supply thoughts selected for similarity with what one has read before, and hence can take a reader out of his or her algorithmically developed bubble.

However, I fear that in losing blogs such as these, we lose important voices that have helped challenge our pre-existing beliefs, illuminated what has gone wrong with health care, and showed us the way forward.

So rest in peace, Health Wonk Review.  I hope that there will be some way to continue the vigor of discussion that characterized it, and other health care blogs which are now defunct.