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[Dec 26, 2019] A pretty neat tool that lets you check if your *own* doctor has taken money from pharmaceutical companies

Dec 26, 2019 |

Max Coleman ‏ 8:49 AM - 22 Dec 2019

A pretty neat tool that lets you check if your *own* doctor has taken money from pharmaceutical companies. https:// tus/1208789881968832515

Max Coleman ‏ 8:23 AM - 22 Dec 2019

These data (see link) are fascinating for sociological as well as political reasons. https:// atus/1208745594153586688

[Dec 24, 2019] Congress refuses to ban surprise billing racket: "We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.

Dec 24, 2019 |

tegnost , December 23, 2019 at 8:49 am

As the days go by I become more convinced that the impeachment drama was used to cover up the passing of the usmca and axing of the venture capital in health care bill and containing surprise medical billing
"We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.


paddlingwithoutboats , December 23, 2019 at 9:14 am

From the KHN article on surprise billing
"surprise medical bills, which generally arise when an insured individual inadvertently receives care from an out-of-network provider."

How did "inadvertently" get in there when it is a revenue generation model? Asymmetry of information is always how profits are made.

I like to invert the model and estimate the outcomes for a lot of these fictions: if working class people controlled the upward distribution of wealth, how would society be different?

Joe Well , December 23, 2019 at 11:11 am

Yves has posted about how private equity firms specifically make this a business model.

[Dec 22, 2019] If you know someone who is severely obese, please advise them to have a Fibroscan to check their liver

Dec 22, 2019 |


kareninca , December 21, 2019 at 4:18 pm

Re the obesity stats. If you know someone who is severely obese, please advise them to have a Fibroscan to check their liver. I have a close relative who is now in stage 5 cirrhosis of the liver due to obesity. Not due to drinking; he did not drink alcohol in excess. He is a college professor; he had all the usual blood tests, which were all fine. But blood tests do not detect cirrhosis. Let me repeat that: blood tests do not detect cirrhosis . He has about a year to live, unless he gets a transplant, he vomits blood and his muscles are wasting. But his liver values on his bloodwork are fine .

Only a biopsy or a Fibroscan can detect this (Fibroscans are not perfect, but they are better than nothing). This relative only found out he had a problem when he had the characteristic bulge on his side, and went to the ER. His only "heads up" was that he was told he had fatty liver. But the cirrhosis diagnosis only came about six months after that.

Not everyone who is severely obese gets cirrhosis. There is a (common) genetic variation which increases the risk; this relative has that variant. Also he ate terrible food all of the time: Dunkin Donuts; Starbursts, McDonald's food. The liver is a filter. You can poison it. Obesity is coming to be a very common cause of cirrhosis. Once you have it, losing weight does not help. If you get cirrhosis from alcohol, stopping drinking can help. But changing your eating does not help, once you get it from obesity. It is not even clear what you should eat at that point (other than not eating toxic horrible stuff); I am not finding good data.

I wanted to give him part of my liver, but I can't; I'm not healthy enough myself. Living donation of part of your liver is a major operation.

[Dec 22, 2019] This neoliberal maggot Schumer managed to defeat 'suprise blling" legistlation

Notable quotes:
"... Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something? ..."
Dec 22, 2019 |

flora , December 21, 2019 at 7:41 am

re:impeachment redux

Interesting, to me at least, that the rocket docket timetable of the House impeachment coincided with the deadline to pass a budget to avoid a(nother) govt shutdown. While all msm eyes were transfixed by the hyperventilating spectacle, behind the scenes the budget passed through the Dem House was filled with more tax breaks for the corporations and the .001%, more money than the admin asked for the MIC, and killed a bill that would end medical 'surprise billing' (another gift to medical PE investors and giant hospital corporations), basically a whole neolib wish list.

Interesting the two events coincided, and, that Nancy decided not to sent on the articles to the Senate at this time. What gives? Is she hold on to them for a future time when she'll need to use them as another distraction for the msm to report on? (no, that could not be the reason. ;) )

Spring Texan , December 21, 2019 at 9:44 am

Schumer and a top House Democrat with ties to private equity were instrumental in defeating the surprise medical bill legislation:

Pat , December 21, 2019 at 2:31 pm

Pointed this out a couple of days ago (Slate and Buzzfeed). Happy that it is not just the online press pointing out it was Democrats killing this measure, Democrats in leadership positions. I also like that few, if any, of our media is falling for the kabuki used by Neal to stick the shiv in. Everyone gets that the 'competing plan' was there strictly to derail a law that end the hugely profitable but fraudulent price gauging of healthcare by private equity.

If he keeps this up, walking POS Schumer might make me miss Al D'Amato nah Al and Chuck are just two different colors of tulle, adding illusion to the political process.

Carey , December 21, 2019 at 3:51 pm

..and they could have just passed it for the good PR and then de-fanged it
administratively, but it looks like they wanted to press the point:
"No, Proles, we're not gonna let you breathe, not a bit."

Good to know.

Joe Well , December 21, 2019 at 11:03 am

Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something?

[Dec 15, 2019] Pete Buttigieg's Corporate Heel-Turn

Who will pay for Medicare for all. This is the question. Because 10% of most sick patient consume 80of all funds it is not that simple quetion. Adter all any medical insurance is in essence putting a value of human life. Is human life is invaluable you need infinite amount of money.
So medical system in the USSR for example, where it cane be called Medicare for all in reality was grossly unfair to old and very sick people. They have limited funds for unlimited demand for their services. And they tried to save first those who they consider more valuable for the society.
So while it is clear that Pete Buttigieg is a well spoken corporate tool, his stance on Medicare for all is not completely obnoxious.
Dec 15, 2019 |

Pete Buttigieg burst on the national scene early this year as a new sort of presidential candidate. But it turns out he's a very old kind -- a glib ally of corporate America posing as an advocate for working people and their families. That has become apparent this fall as Buttigieg escalates his offensive against Medicare for All.

A not-so-funny thing has happened to Buttigieg on the campaign trail. As he kept collecting big checks from corporate executives and wealthy donors, he went from being " all for " a single-payer Medicare for All system in January to trashing it in the debate last week as a plan that would kick "150 million Americans off of their insurance in four short years." The demagoguery won praise from corporate media outlets.

Those outlets have often lauded Buttigieg for his fundraising totals this year without scrutiny of the funding sources. They skew toward the wealthy -- and toward donors with a vested interest in protecting the status quo.

[Dec 15, 2019] The 5 Keys to Falling Asleep On Time Every Night

Dec 15, 2019 |

The best book I've read on sleep is Matthew Walker's Why We Sleep . In it, he explains the importance of getting good sleep as well as offers suggestions for how to avoid problems of nighttime insomnia. Here are a few strategies you can apply to sleep better:

1. Reduce light levels (especially blue and white light) before bed.

The body uses two different hormone systems for signaling the need to sleep. One of these is managed by melatonin and is influenced by light levels. This creates our circadian rhythm of night and day. It's also responsible for jet lag, as our mental clock is out of sync with the actual clock, resulting in struggling to sleep at night and napping all day whenever you have to travel overseas.

This melatonin system is influence by light. Unfortunately, in our modern environment we are constantly illuminated by bulbs and screens, making it easy for this system to get out of sync.

Tip: If you struggle getting to sleep early, make it a habit to use minimal lighting (or no lighting) an hour before bed. I often listen to audiobooks in a mostly dark room as I try to fall asleep. Avoid LED screens which have more blue light, and are more likely to trick your brain into thinking it's daytime.

2. Avoid caffeine after noon (including decaf coffee).

Caffeine interacts with the second of the two hormone systems our bodies use for sleep. As we go longer without sleep we accumulate adenosine. Receptors watch for levels of adenosine and push us to sleep when it has been a long time without shut eye. Caffeine, in turn, temporarily "plugs" these receptors so they can't deliver the sleep signal they normally would.

The problem, however, is that caffeine doesn't actually remove adenosine from your body (or give the restorative benefits of sleep), so when it finally breaks down, all the adenosine that was present before comes back and can make you feel worse than before. Sometimes, this can lead to the urge to have a second cup (or fourth) in the afternoon, to push through the rest of the day.

Unfortunately this can also interfere with later sleep. Caffeine loses its immediate kick soon, but it has a surprisingly long half-life in the brain, meaning even hours after drinking it, there is still a non-trivial amount in your system. Decaf coffees, while having much less caffeine than normal, still have non-trivial amounts of caffeine, so a decaf after dinner might also make it harder to sleep.

3. Sleep the same time on weekdays and weekends.

I know, I know. Easier said than done. Weekends are a good time for socializing, and who wants to be the person going home to bed at nine pm?

Still the benefits of a consistent sleeping schedule may make up for the occasional social interference. Staying up late, especially if you struggle to sleep in fully, can mean you're not getting a full night's rest on weekends. This is particularly true if you drink alcohol before sleeping, which can interfere with the brain processes of sleep that make it restorative. Do this regularly and it's no wonder you're always exhausted.

Sleeping habitually at the same time is a good way to prevent missing sleep.

4. Watch out for naps.

If you struggle with falling asleep (or staying asleep) then the fatigue can push you to take naps in the day. However, as Walker points out in his book, napping can alleviate some of the adenosine build-up, which conversely, makes it harder to fall back asleep at night time.

I certainly struggle with this advice myself, as I often take quick naps in the early afternoon. I do think a short nap (15-20 minutes) is preferable to a long one, if only because it has a lesser impact on later sleeping.

5. Get help from your family.

For some, going to sleep is an entirely independent choice. However for many of us (myself included) going to sleep usually means going to sleep with your spouse (or having them come in after while you're already trying to sleep). Therefore, when working on a new sleeping habit, it's important to communicate your goals and motivations. If you don't talk about it, then the habit likely won't last as you stay up to watch another episode of Stranger Things.

This article was originally published on July 15, 2019, by Scott Young, and is republished here with permission.

[Dec 08, 2019] Something to keep in Mind when you enroll in Medicare Advantage Plans

Dec 07, 2019 |
It is not a dirty or hidden little secret. Insurance companies offering MA plans do not tell you that once you are in their plan, you are there potentially forever.

Returning to traditional Medicare is ok but, getting a Medigap Plans to supplement the gap may lead to rejection or much higher premiums if you choose to come back and especially if their are pre-existing conditions.

The same as the Commercial MA companies, websites are not always clear about the process of transferring out of MA to traditional Medicare and obtaining a Medigap plan.

Being unconditionally accepted by a Medigap plan is guaranteed only within the first 12 months after enrolling in Medicare at age 65.

In 2019, one-third (34%) of all Medicare beneficiaries, 22 million seniors were enrolled in Medicare Advantage (MA) plans.

As most know, Medicare consists of Part A, B, C, and D plans.

To cover the gaps in A & B and the gap, you buy supplemental insurance which is about the same as Part B in premium cost. Unless Medicare rules change, the most one can experience is changes in premiums.

In contrast, Part C or Medicare Advantage plans can cover a broad array of health services at a low cost. Unless one gets sick, the price for MA Plans can remain low. If one does gets sick, out-of-pocket costs can increase in later years . Once in an MA plan, getting out can result in less affordability. Medigap plans in all but four states can and do reject people or require higher premiums if you came back to them after Medicare Advantage Plans. Diabetes, heart disease, or even a knee replacement can be criteria for exclusion.

"After Mills underwent a mitral valve repair and suffered a mild stroke with no lasting effects, the San Diego resident's plan now charges him hundreds of dollars in monthly copays for drugs and other medical services. He had to pay $295 a night for his hospital stay.

But there was a much bigger shock. Mills, 71, learned that switching out of his MA plan he would incur exorbitantly higher costs the next time he needs a serious medical intervention. If he moves to traditional Medicare and a prescription plan, he will still need a supplemental Medigap plan to pick up his 20% copays and deductibles."

Again, this is something most people do not know, an should know before they make any move to Medicare Advantage plans. Furthermore, there are many MA plans which have narrow networks to which you must go to. In comparison, traditional Medicare pays where ever you go in the United States.

Comments (4)

davebarnes , December 7, 2019 1:25 pm

" if their are pre-existing conditions" really? perhaps if there are would be better

davebarnes , December 7, 2019 1:29 pm

All you wrote is true. But, I really like my Kaiser Advantage plan. My total cost for colon cancer (including surgery, chemo) was $2500. My total cost for a perianal abscess (3 surgeries) was $300.

run75441 , December 7, 2019 2:19 pm

My total cost for being in the hospital for 3.5 weeks and 4 doses of Rituxan was less than $1000 under Traditional Medicare and Plan N Supplemental. Medicare Advantage is problematic. Premiums can go up in Traditional but out of pocket is stable.

Carol , December 7, 2019 1:45 pm

@davebarnes i agree, but KP isn't available nationwide, and it is problematic getting the same coverage elsewhere

[Nov 30, 2019] American Life Expectancy Dropping Dramatically Thanks To White Working Class Male Suicides

Notable quotes:
"... Authored by Paul Joseph Watson via Summit News, ..."
"... a "distinctly American phenomenon," ..."
"... My voice is being silenced by free speech-hating Silicon Valley behemoths who want me disappeared forever. It is CRUCIAL that you support me. Please sign up for the free newsletter here . Donate to me on SubscribeStar here . Support my sponsor – Turbo Force – a supercharged boost of clean energy without the comedown. ..."
Nov 29, 2019 |

Authored by Paul Joseph Watson via Summit News,

After increasing for decades, American life expectancy is now facing an alarming decline thanks mainly to suicides of white working age men.

A study published by the journal JAMA, found that life expectancy in America increased from 1959 to 2014 but that the number plateaued in 2011 and began decreasing in 2014.

"The study... found that the decline is mostly among "working-age" Americans, or those ages 25 to 64 ," reports Live Science .

"In this group, the risk of dying from drug abuse, suicide, hypertension and more than 30 other causes is increasing. "

The decline in life expectancy for working aged males has not been recorded in other developed countries and is a "distinctly American phenomenon," according to study co-author Steven H. Woolf of Virginia Commonwealth University School of Medicine.

According to Lisa Britton, CNN's coverage of the story omitted the crucial point that the decline was being driven by male suicides.

" CNN just did a piece on the declining life-expectancy rate in the US and failed to mention it's the MEN's rate that is declining! Women have maintained a steady rate although there's been an uptick in the women's overdose rate (The Wash Post turned their story into that) Wow," she tweeted.

As we discuss in the video below, the only demographic group that has seen a dramatic rise in suicides and "deaths of despair" is white, middle aged, working class men.



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Despite this, the media and the culture still relentlessly blames that same demographic for both historical and contemporary societal ills, de-legitimizing their trauma under the rubric of "white privilege."

* * *

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sbin , 2 minutes ago link

Same thing happened when CCCP was collapsing.

USSA history doesn't repeat but seems very familiar.

[Nov 26, 2019] Beware of the Medicare Disadvantage Corporate Trap Wake Up AARP by Ralph Nader

Nov 25, 2019 |
While the Democratic presidential candidates are debating full Medicare for All, giant insurance companies like UnitedHealthcare are advertising to the elderly in an attempt to lure them from Traditional Medicare (TM) to the so-called Medicare Advantage (MA) – a corporate plan that UnitedHealthcare promotes to turn a profit at the expense of enrollees.

Almost one third of all elderly over 65 are enrolled in these numerous, complex MA policies the government pays so much for monthly. The health insurance industry wants more enrollees as they continue to press Congress for more advantages.

Medical Disadvantage would be a more accurate name for the programs, as insurance companies push to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.

Elderly people enrolled in MA will experience its often merciless denials when they get sick. As hospital expert – attorney, physician, Dr. Fred Hyde put it: "It's not just what you pay, it's what you get."

Start with the cross-subsidy of MA from TM. In 2009, the Congressional Budget Office estimated these overpayments would cost the federal government $157 billion over the coming decade. Obama's Affordable Care Act started to reduce these subsidies to the giant insurers, but they still amount to many billions of dollars per year.

Add that with Medicare Disadvantage you are restricted to networks of vendors. That restricts your choice for competence and skills, and sometimes, requires you to travel longer distances for treatment. This could mean fewer enrollees will utilize their healthcare and more profits for the insurance companies.

Under Medicare Disadvantage you are subject to all kinds of differing plans, maddening trapdoor fine print, and unclear meaning to the insurers arguing no "medical necessity" when you're denied care.

The advertisements for Medicare Disadvantage stress that you can sometimes get perks – gym memberships, hearing aids, and eyeglasses, as enticements, but they avoid telling you they are not so ready to cover serious needs like skilled nursing care for critically ill patients.

Under Medicare Disadvantage, there is no Medigap coverage as there is for TM. Co-pays and deductibles can be large. Under a recent Humana Medicare Advantage Plan in Florida, your co-pay for an ambulance is up to $300, up to $100 co-pay for lab services, and another $100 for outpatient x-rays.

A few years ago, UnitedHealthcare corporations dismissed thousands of physicians from their MA networks, sometimes immediately, sometimes telling their patients before telling their physicians.

Dr. Arthur Vogelman, a gastroenterologist, said he received a termination letter in 2013 from UnitedHealthcare. He appealed, documenting his successful treatment of many patients. The company denied his appeal, with no reason, as it had for thousands of network physicians.

Dr. Vogelman called it "an outrage. I have patients in their 80s and 90s who have been with me 20 years, and I'm having to tell them that their insurer won't pay for them to see me anymore. The worst thing is I can't even tell them why." Except that the company wanted more profits.

After a lengthy protest by national and state medical societies in 2013, UnitedHealthcare began to be less aggressively dismissive.

Studies show the main reason MA enrollees return to TM is how badly the corporate insurers treated them when they became sick.

Medicare itself is getting overly complex. But nothing like the ever changing corporate rules, offerings, and restrictions of Medicare Disadvantage. How strange it is that AARP, with its Medigap insurance business run by UnitedHealthcare, doesn't advise its members to go with the obviously superior Traditional Medicare. AARP reportedly receives a commission of 4.95% for new enrollees on top of the premiums the elderly pay for the Medigap policy from United Healthcare. This money – about seven hundred million dollars a year – a significant portion of AARP's overall budget.

AARP responded to my inquiries into their Medicare Advantage policy saying that it does not recommend one plan over another, leaving it to the less informed consumer. That's one of AARP's biggest cop-outs -- they know the difference.

There is no space here to cover all the bewildering ins and outs of what corporations have done to so-called managed Medicare and managed Medicaid. That task is for full-time reporters. The government does estimate a staggering $60 billion in billing fraud annually just on Medicare – manipulating codes, phantom billing, etc. You need the equivalent of a college-level course just to start figuring out all the supposed offerings and gaps.

Suffice it to say that, in the words of Eleanor Laise, senior editor of Kiplinger's Retirement Report, "the evidence on health care access and quality decidedly favors original Medicare over Medicare Advantage, according to a Kaiser Family Foundation review of 40 studies published between 2000 and 2014."

All this anxiety, dread, and fear, all these arbitrary denials of care – prompted by a pay-or-die commercial profit motive – all these restrictions of what doctors or hospitals you can go to, do not exist in Canada. All Canadians have a Medicare card from birth; they have free choice of health care vendors. There are few American-style horror stories there; patients have better outcomes, and almost never even see a bill. The whole universal system costs half per capita of that in the U.S., where over 80 million people are uninsured or underinsured – still! (See, for civic action to rid Americans of this perverse chaos). Join the debate on Facebook More articles by: Ralph Nader

Ralph Nader is a consumer advocate, lawyer and author of Only the Super-Rich Can Save Us!

[Nov 14, 2019] the Caribbean investment also illustrates how dramatically U.S. health care is changing. In its rapid-fire evolution, Ascension has become a leading example of a nonprofit health system that often acts like a for-profit, blurring the line between businesses and charities.

Nov 14, 2019 |

Krystyn Walentka , November 13, 2019 at 12:36 pm

Please look into Ascention healthcare if you want to know how completely effed up this whole situation is!

That dramatic growth culminates Tuesday with the grand opening in the Cayman Islands of the first phase of a $2 billion "health city" complex -- a project that seems far removed from the nonprofit health system's humble origins and its Catholic mission to serve the poor and vulnerable.

Ascension executives say they hope through this joint venture with a for-profit, India hospital chain to learn ways to reduce medical costs.

But the Caribbean investment also illustrates how dramatically U.S. health care is changing. In its rapid-fire evolution, Ascension has become a leading example of a nonprofit health system that often acts like a for-profit, blurring the line between businesses and charities. Its health ministry has drawn criticism for risk-taking and its ties to Wall Street. And some critics have raised questions about its tax-exempt status.

[Nov 09, 2019] The Managers' Coup d'Etat in Health Care Appears Complete - a Study of Top Health Care Influencers

Nov 09, 2019 |

The authors concluded that

perceived influence over US health care of chief executives of health systems is increasing. To the extent that the ranking validly reflects influence, the sharp rise in the influence of chief executive officers at the expense of representatives of patients or health professionals may underscore the increasing industrialization of health care. It is not possible to find patients, patient advocates, clinicians, or clinician advocates at the top of this list . This trend placing health care influencers within C-suites, accountable to boards mostly comprising other corporate leaders, may explain the rise of business language and thinking

They suggested that it is possible that there is a

causal association between the concentration of executive influence and problems of patient care derived from efforts to optimize operational efficiency and financial performance, for example, clinician burnout , the heavy burden of treatment afflicting patients with chronic conditions, and the erection of barriers to care to optimize 'payer mix.'

Dr Montori also said in the interview

Americans increasingly find themselves in a corporate-centric healthcare echo-chamber , one in which the public will increasingly approach tough policy decisions having heard only the viewpoint from the top.

'The primary goals of CEOs are to advance the mission of their organization,' Montori says. 'If all that influences healthcare are the ideas of people who advocate for the success of their organizations, people who are not served by them will not have their voices heard.'

Furthermore, he suggested that the public may be befuddled by the current health policy debates, including those about universal health care and the possibility of reducing the power of commercial health insurance companies because

in the rest of the narrative all that they hear is about are the successes of biotech, the successes of tech companies, and the successes of healthcare corporations who achieve high levels of innovation thanks to the bold leadership of their executives. It's why we have been calling for greater awareness of the industrialization of healthcare for some time now


The new study by Longman, Ponce, Alvarez-Villalobos and Montori adds to the evidence that health care has been taken over by business-trained managers, and in the US, especially by large commercial health care organizations run by such managers.

Since we started Health Care Renewal , we have frequently discussed the rise of generic managers, which later we realized has been called managerialism. Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work. Managerialism has become an ascendant value in health care over the last 30 years. The majority of hospital CEOs are now management trained, but lacking in experience and training in medicine, direct health care, biomedical science, or public health. And managerialism is now ascendant in the US government. Our president, and many of his top-level appointees, are former business managers without political experience or government experience.

We noted an important article in the June, 2015 issue of the Medical Journal of Australia(1) that made these points:

– businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
– this change was motivated by neoliberalism (also known as economism or market fundamentalism )
– managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
– managerialism makes short-term revenue the first priority of all organizations
– managerialism undermines the health care mission and the values of health care professionals

Generic or managerialist managers by definition do not know much about health care, or about biomedical science, medicine, or public health. They are prototypical ill-informed leadership , and hence may blunder into actual incompetence. They are trained that they have a right to lead any sort of organization, which breeds arrogance. These managers are not taught about the values of health care professionals. Worse, they are taught in their business style training about the shareholder value dogma, which states that the main objective of any organization is to increase revenue. Thus, they often end up hostile to the fundamental mission of health care, to put care of the patient and the health of the population ahead of all other concerns, which we have called mission-hostile management. (Furthermore, it appears that the shareholder value dogma is just smokescreen to cover the real goal of managers, increasing their own wealth, e.g., look here .) Finally, arrogance and worship of revenue allows self-interested and conflicted, and even sometimes corrupt leadership.

Managerialists may be convinced that they are working for the greater good. However, I am convinced that our health care system would be a lot less dysfunctional if it were led by people who actually know something about biomedical science, health care, and public health, and who understand and uphold the values of health care and public health professionals – even if that would cost a lot of very well paid managerialists their jobs.

Maybe someday the top "influencers" in health care will actually be people who know something about health care and actually care about patients' and the public's health.

1 Kings , November 9, 2019 at 4:51 am

'We've got to protect our phoney-baloney jobs, gentlemen.' William J. Le Petomane

James Miller , November 9, 2019 at 4:58 am

John Raulston Saul, in "Voltaire's Bastards", has produced an intellectual fireworks display that deals directly with the problem Dr.Poses sees pretty clearly. Endhoven proposes an attack on what he sees as a regressive medieval remnant, a Guild, an attack that has been pretty successful in a broad swath of our neoliberal world. Saul would recognize that attack immediately, and despise it. It's what he wrote about with such fiery contempt.. And in my opinion, he's right.

Managerialists, purveyors of "reason", are leaving a trail of disaster in pretty much every area where their influence is powerful. Their ivy league, MBA-dominated education seemingly has failed to provide any sense of the human feelings and needs that must be an essential part of successful planning or policy. The bottom line trumps all else, and generates disaster as well as shareholder value. Treat yourself, as well as tantalize your wits. Read it.

flora , November 9, 2019 at 5:20 am

Thanks for this post. Two quotes that sum up much of the overpriced disfunction, imo.

Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.

Better leaders toward what goal?

– managerialism makes short-term revenue the first priority of all organizations

Brooklin Bridge , November 9, 2019 at 6:54 am

managerialism makes short-term revenue the first priority of all organizations

Except when it comes to manufacturing ideologies. There, they are quite capable of taking the long view with think tanks, generational influence (stacking) of the judical system, education, politics and policy and so on.* It's not as if they are unaware of the concept of laying foundations. But short term revenue seems to be tightly coupled in their view to what they get to put in their pockets which in turn (perhaps ironically by the foundation builders: self worth by comparative metrics) has been tightly coupled to their perceived worth as human beings.

(Ultimately, I believe, the phenomenon of comparative metrics literally projects the homeless -or in this case the paucity of care for whole segments of society- into existence and maintains their numbers in relation to those of the "managers.") Interestingly, the mix of origins, whether such seminal ideas ( "eat your vegetables, think of the starving Chineese" ) are vernacular and borrowed and repurposed or canonical and disseminated helps in no small part to obscure the process.

*Even if the managers are not always the drivers, they are aware of the value.

Synoia , November 9, 2019 at 6:12 am

When doctors graduate from medical school with $500,000 in debt, what is the primary lesson they have learned?

[Nov 04, 2019] California Nursing Home Residents Told To Find New Homes

Nov 04, 2019 |

Henry Moon Pie , November 1, 2019 at 6:20 am

We've created a society where it's necessary for all able-bodied adults in a nuclear family to work long hours to maintain a "middle class lifestyle." There's no time left for looking after children or the elderly as humans were once wont to do.

Human productivity has reached a point where life could be rather easy and pleasant for everybody in our society, but we're organized to make life as full of drudgery, anxiety and empty materialism as possible. "Experts" decide that the elderly must first divest themselves of everything but their toothbrush in order to receive otherwise unaffordable nursing home care, then another "expert" comes along and advises the state to save money by requiring some of those penniless patients to depend on in-home care when they've already been stripped of a home. What would we ever do without these brilliant "experts?"

If you've ever spent much time in a nursing home, you know what an awful solution it is for the problems of aging and infirmity. It's also very expensive even when the highly stressed workers are paid a pittance. If our entire society weren't organized around making a few people bizarrely rich, maybe we could go back to caring for children and the aged within families and small community groups.

[Oct 27, 2019] It turns out that the real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided

Oct 27, 2019 |

Health Care

"The Urban Institute's Single Payer Cost Estimate: False Assumptions False Conclusions" [David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H., PNHP ]. The Urban Institute study was instantly signal-boosted by CNN , the Hill , and The Atlantic , among others, and seems to have led to the "pay for" questions in the last debate, and Warren taking on the task -- not planned already? -- of writing a tax proposal for whatever she determines Medicare for All to actually be. "Administrative savings, Part 1: The UI report assumes that single-payer reform would reduce insurance overhead to 6% of claims ($234 billion) from the current level of about 10.6%. In contrast, overhead in Canada's single-payer system is only 1.8%, and overhead in the fee-for-service Medicare program is 2%. The UI group justifies its 6% estimate by claiming that a single payer system " would require a host of administrative functions to effectively operate, such as rate setting for many different providers and services of different types; quality control over care provision; development, review, and revision of regulations; provider oversight and standards enforcement; claims payments to providers; and other functions." UI's claim ignores the fact that all of these functions are currently carried out by both Canada's program and the fee-for-service Medicare program." • This is a brutal takedown of the Urban Institute study, which you should read in full.

"What the Health Care Debate Still Gets Wrong" [Adam Gaffney, The Boston Review ]. "[T]his entire edifice of reform [ObamaCare ACOs] was built on sand. Quite simply, as a nation, we actually do not use too much health care; if anything, we use fewer services than people in other high-income countries. While 'overutilization' may indeed be a major problem in some areas (and who wants an unnecessary slice from a scalpel?), it cannot, simply as a matter of basic accounting, explain our total off-the-charts spending. In particular, it cannot account for the fact that we spend more than $10,000 per capita on health care -- approximately double that of Canada -- nor for the nearly six-fold rise in inflation-adjusted healthcare spending from 1970 to 2017, according to estimates from the Kaiser Family Foundation. The real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided. So what can? It turns out that the real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided. This simple but crucial insight is most frequently attributed to the legendary health economist Uwe Reinhardt."

"A New Generation of Activist Doctors Is Fighting for Medicare for All" [ Time ]. "[Travis Singleton, executive vice president of Merritt-Hawkins], whose firm conducts a biennial survey of doctors' opinions, says that while there are myriad reasons for an uptick in political involvement, one of the most compelling is simple: doctors see the dysfunction of the health care system on a daily basis. As health care costs ballooned and the private insurance industry expanded, the job of being a doctor changed. Instead of just treating patients, doctors today must battle with insurance requirements, manage arcane reimbursement systems and juggle enormous administrative costs, Singleton's firm found. Much of this is a direct consequence of physicians' early opposition to health care reform, explains Beatrix Hoffman, a history professor at Northern Illinois University. By pushing back against government involvement, she says physicians created the system that is now dominated by private insurance. 'We've heard so many horror stories from doctors who have come before us about spending hours on the phone negotiating with insurance companies,' says Scott Swartz, a 28-year-old medical student in San Francisco. 'That's not how we want to spend our time.' All of these factors have combined to shift doctors' politics to the left." • But patients love their insurance companies. Right?

"We Found Over 700 Doctors Who Were Paid More Than a Million Dollars by Drug and Medical Device Companies" [ Pro Publica ]. "Back in 2013, ProPublica detailed what seemed a stunning development in the pharmaceutical industry's drive to win the prescription pads of the nation's doctors: In just four years, one doctor had earned $1 million giving promotional talks and consulting for drug companies; 21 others had made more than $500,000. Six years later -- despite often damning scrutiny from prosecutors and academics -- such high earnings have become commonplace. More than 2,500 physicians have received at least half a million dollars apiece from drugmakers and medical device companies in the past five years alone, a new ProPublica analysis of payment data shows. And that doesn't include money for research or royalties from inventions."

[Oct 23, 2019] Air Pollution 'Triggers Hundreds More Heart Attacks and Strokes,' Study Finds

Oct 23, 2019 |

( 40 BeauHD on Monday October 21, 2019 @11:30PM from the avoidable-deaths dept. An anonymous reader quotes a report from the BBC: Higher air pollution in the UK trigger hundreds more heart attacks, strokes and acute asthma attacks each year , research suggests. A team at King's College London looked at data from London, Birmingham, Bristol, Derby, Liverpool, Manchester, Nottingham, Oxford and Southampton. They calculated days with above average pollution levels would see an extra 124 cardiac arrests over the year. On days with high pollution levels, across the nine cities in total, they calculated that there would be a total of 231 additional hospital admissions for stroke, with an extra 193 children and adults taken to hospital for asthma treatment. Dr Heather Walton, of King's College London's Environmental Research Group, said air pollution reduction policies concentrated in the main on effects connected to life expectancy.

In London, high-pollution days would see an extra 87 cardiac arrests per year, an extra 144 strokes, and 74 children and 33 adults ending up in hospital with asthma-related issues. In Birmingham the figure would be 12 more out-of-hospital cardiac arrests, 27 additional admissions for stroke and 26 more for asthma. Bristol, Liverpool, Manchester, Nottingham, Oxford and Southampton would see between two and six more out-of-hospital heart attacks and up to 14 extra hospital admissions for both stroke and asthma. Only in Derby would there be no apparent increase. The research suggests cutting air pollution by a fifth would decrease incidents of lung cancer by between 5% and 7% across the nine cities surveyed.

[Oct 22, 2019] Exposure To Air Pollution is Linked To an Increase in Violent Crime (

Looks like pseudoscience to me... which is not surprising from Economist...
Oct 22, 2019 |
linked to aggressive behavior , according to a new paper by Jesse Burkhardt and his colleagues at Colorado State University and the University of Minnesota. Using crime data from the Federal Bureau of Investigation and air-pollution data from the Environmental Protection Agency, the authors analyse the link between air pollution and violent crime in 397 American counties between 2006 and 2013. From a report:

They find that a 10% increase in same-day exposure to PM2.5 (particulate matter less than 2.5 microns in diameter) is associated with a 0.14% increase in violent crimes, such as assault. An equivalent increase in exposure to ozone, an air pollutant, is associated with a 0.3% jump in such crimes.

Pollution levels can easily rise by much more than that. Last November, owing to wildfires, PM2.5 levels in San Francisco rose seven times higher than average.

Correlation is not causation of course (there may, for example, be a third variable affecting both pollution and crime) and the authors are cautious not to speculate about the precise mechanism by which contaminated air might lead to more rapes or robberies. This is not the first time researchers have identified a relationship between pollution and crime.

In the 1970s America banned lead-based paint and began phasing out leaded petrol; two decades later, crime fell. Many researchers now argue that the two developments were linked. In a paper published in 2007, Jessica Wolpaw Reyes, an economist at Amherst College, estimated that the drop in lead exposure experienced by American children in the 1970s and 1980s may explain over half of the decline in violent crime in the 1990s.

[Oct 20, 2019] Researchers Detail How Slashing Pentagon Budget Could Pay for Medicare for All While Creating Progressive Foreign Policy Americ

Notable quotes:
"... "Over 18 years, the United States has spent $4.9 trillion on wars, with only more intractable violence in the Middle East and beyond to show for it," she added. "That's nearly the $300 billion per year over the current system that is estimated to cover Medicare for All (though estimates vary)." ..."
"... cancellation of current plans to develop more nuclear weapons, saving $20 billion a total nuclear weapons ban, saving $43 billion ending military partnerships with private contractors, saving $364 billion production cuts for the F-35 -- a military plane with 900 performance deficiencies, according to the Government Accountability Office -- saving $17.7 billion a shift of $33 billion per year, currently used to provide medical care to veterans, servicemembers, and their families, to Medicare for All's annual budget. ..."
"... "The public rejects the predominant, fear-based framing and policies; instead, they want to see a revamped, demilitarized American foreign policy focused on international cooperation, human rights, and peacebuilding," wrote Data for Progress. ..."
Oct 18, 2019 |

Yves here. For those of you who have friends and colleagues who would go on tilt if you tried educating them about MMT, a simpler approach to persuade them that Medicare for All is affordable is to sell them on another worthy goal, cutting the military-surveillance state down to size.

Even then, I still encourage you to set them up for a later conversation about MMT: "Even if you accept the idea that taxes pay for spending, which actually isn't true for the Federal government, we can still get the money for Medicare for All by ."

Note also that the Pentagon has various black budgets, an "official" one and covert ones.

By Julia Conley, staff writer for Common Dreams. Originally published at Common Dreams

The Institute for Policy Studies on Thursday shared the results of extensive research into how the $750 billion U.S. military budget could be significantly slashed, freeing up annual funding to cover the cost of Medicare for All -- calling into question the notion that the program needs to create any tax burden whatsoever for working families.

Lindsay Koshgarian, director of the National Priorities Project at the Institute for Policy Studies (IPS), took aim in a New York Times op-ed at a "chorus of scolds" from both sides of the aisle who say that raising middle class taxes is the only way to pay for Medicare for All. The pervasive claim was a primary focus of Tuesday night's debate, while Medicare for All proponents Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) attempted to focus on the dire need for a universal healthcare program.

At the Democratic presidential primary debate on CNN Tuesday night, Sen. Elizabeth Warren (D-Mass.) was criticized by some opponents for saying that "costs will go down for hardworking, middle-class families" under Medicare for All, without using the word "taxes." Sen. Bernie Sanders (I-Vt.), on the other hand, clearly stated that taxes may go up for some middle class families but pointed out that the increase would be more than offset by the fact that they'll no longer have to pay monthly premiums, deductibles, and other medical costs.

"All these ambitious policies of course will come with a hefty price tag," wrote Koshgarian. "Proposals to fund Medicare for All have focused on raising taxes. But what if we could imagine another way entirely?"

"Over 18 years, the United States has spent $4.9 trillion on wars, with only more intractable violence in the Middle East and beyond to show for it," she added. "That's nearly the $300 billion per year over the current system that is estimated to cover Medicare for All (though estimates vary)."

"While we can't un-spend that $4.9 trillion," Koshgarian continued, "imagine if we could make different choices for the next 20 years."

Koshgarian outlined a multitude of areas in which the U.S. government could shift more than $300 billion per year, currently used for military spending, to pay for a government-run healthcare program. Closing just half of U.S. military bases, for example, would immediately free up $90 billion.

"What are we doing with that base in Aruba, anyway?" Koshgarian asked.

Other areas where IPS identified savings include:

"This item takes us well past our goal of saving $300 billion," Koshgarian wrote of the last item.

As Koshgarian published her op-ed in the Times , progressive think tank Data for Progress released its own report showing that a majority of Americans support a "progressive foreign policy" far less focused on decades-long on-the-ground wars, establishing military bases around the world, drone strikes, and arms sales.

"The public rejects the predominant, fear-based framing and policies; instead, they want to see a revamped, demilitarized American foreign policy focused on international cooperation, human rights, and peacebuilding," wrote Data for Progress.

"Voters want to see U.S. funding go to domestic needs such as healthcare, or to other national security tools like diplomacy, instead of to the Pentagon and more endless war," according to the report.

Polling more than 1,000 ppl with YouGov, Data for Progress found that 73 percent of Democratic primary voters ranked numerous issues -- including economic challenges and the climate -- as more important to them than national security and military funding.

Progressive national security proposals proved popular with respondents, including closing Guantanamo Bay, ending arms sales to Saudi Arabia, and leveraging military aid to Israel to force it to adopt better human rights policies toward Palestinians.

"There is a clear appetite for progressive reforms to U.S. foreign policy," wrote Data for Progress.

In her op-ed, Koshgarian acknowledged that remaking the U.S. military as a truly "defense-based institution, rather than a war machine and A.T.M. for private contractors, will require major changes."

But, she wrote, "that's no excuse for continuing to spend hundreds of billions in ways that make our world more dangerous and deny us the ability to seriously invest in things like jobs, healthcare, education, and all that makes our lives better."

inode_buddha , October 18, 2019 at 4:39 am

I would love to see it, but I strongly doubt this would happen in my lifetime. The Pentagon budget seems to be one of those political "third rail" issues like Social Security.

Many people are so paranoid that I think it constitutes a mass hysteria; others are propagandized into 24ื7 jingoism. I'm not talking concepts here, I deal with pro-military people almost daily. Its the glorifying and fetishizing of the military that bothers me.

Most if not all pro-military types are also deeply conservative; bring up *any* social program and they will wonder how to pay for it.

Kurt Sperry , October 18, 2019 at 7:26 am

I don't know, how many "third rail" type taboos has Trump danced on and become more popular because he did? I think the average voter would be *extremely* receptive to a well-crafted message promoting the redirection of resources away from forever foreign wars and bases to concrete material benefits for Americans. I don't even think it'd be a hard sell, once the pearls had been gathered up.

Michael , October 18, 2019 at 7:59 am

It was done before starting in 1990.
Defense Base Closure and Realignment Act.

An amazing process.

dcrane , October 18, 2019 at 5:13 am

What's so maddening about this question is the fact that we know that the military budget is probably much more than 750 billion per year, but we can never know how much more, because the government is expressly allowed to hide and even fake spending totals.

GF , October 18, 2019 at 11:37 am

Here is an example of unbridled government spending and it is happening right this minute on wall street. It seems the military budget is chump change compared to this:

Sound of the Suburbs , October 18, 2019 at 5:42 am

Why do we worry about money more than anything else?
All money is easy; it comes out of nothing and is just numbers typed in at a keyboard.

Zimbabwe found it all too easy to create so much money they caused hyper-inflation.

Alan Greenspan tells Paul Ryan the Government can create all the money it wants and there is no need to save for pensions.

What matters is whether the goods and services are there for them to buy with that money, and this is where real wealth lies.

Governments can create all the money they want, but if they create too much you will get inflation, or hyper-inflation if they type in too many zero's when creating money.

Money has no intrinsic value; its value comes from what it can buy.

Banks create money from loans and that's easy too, just type the numbers in.

They can dash wildly into the latest fad, like the boom, and finance it with money they create out of nothing.

What could possibly go wrong?

Bankers do need to ensure the vast majority of that money gets paid back, and this is where they keep falling flat on their faces.

Banking requires prudent lending, that is all there is to it.

If someone can't repay a loan, they need to repossess that asset and sell it to recoup that money. If they use bank loans to inflate asset prices they get into a world of trouble when those asset prices collapse.

"It's nearly $14 trillion pyramid of super leveraged toxic assets was built on the back of $1.4 trillion of US sub-prime loans, and dispersed throughout the world" All the Presidents Bankers, Nomi Prins.

When this little lot lost almost all its value overnight, the Western banking system became insolvent. Wall Street can turn a normal asset price bubble into something that will take out the global economy using leverage.

Bankers create money out of nothing and the monetary system requires that nearly all that money they loaned out gets paid back.

Bank credit is a claim on future prosperity, and when you realise all that debt can't be paid back, a financial black hole opens up, as it did in 2008.

When governments create too much money you tend to see it in consumer price inflation.
When banks create too much money you tend to see it in asset price inflation.

We see inflation in asset prices as good and consumer price inflation as bad.

The asset price boom will crash the economy, but no one realises while it's happening.

Sound of the Suburbs , October 18, 2019 at 5:43 am

Asset price inflation.
Financial assets are limited in supply.
Pour more money in and the price goes up.

1929 – Inflating the US stock market with debt (margin lending)
2008 – Inflating the US real estate market with debt (mortgage lending)

Bankers inflating asset prices with the money they create from loans.

They believed in the markets and neoclassical economics in the 1920s and after 1929 they had to reassess everything. They had placed their faith in the markets and this had proved to be a catastrophic mistake.

This is why they stopped using the markets to judge the performance of the economy and came up with the GDP measure instead.

In the 1930s, they pondered over where all that wealth had gone to in 1929 and realised inflating asset prices doesn't create real wealth, they came up with the GDP measure to track real wealth creation in the economy.

The transfer of existing assets, like stocks and real estate, doesn't create real wealth and therefore does not add to GDP. The real wealth creation in the economy is measured by GDP.

Inflated asset prices aren't real wealth, and this can disappear almost over-night, as it did in 1929 and 2008.

Real wealth creation involves real work, producing new goods and services in the economy.

notabanktoadie , October 18, 2019 at 10:03 am

Banking requires prudent lending, that is all there is to it. Sound of the Suburbs

100% private banks with 100% voluntary depositors means we (the general public) wouldn't have to give a flip if banks lent prudently or not since we would have an additional but risk-free payment system consisting of debit/checking accounts for all who want one at the Central Bank (or Treasury) itself.

Moreover without government privileges and without captive depositors and unable to hold the economy hostage via a SINGLE payment system that must work through them, you can rest assured that banks WOULD lend prudently or go under, like they should, if they don't.

So what is required is 100% private banks with 100% voluntary depositors and that situation has NEVER before existed in history so it cannot be said to have failed.

notabanktoadie , October 18, 2019 at 10:31 am

When governments create too much money you tend to see it in consumer price inflation. Sound of the Suburbs

Because the DEMAND for fiat is suppressed in that only depository institutions may use it in the private sector.

Fix that injustice and eliminate all other privileges for banks and then government should be able to create much MORE fiat for the general welfare since banks would be much LESS able to create deposits for the private welfare of themselves and for the so-called "worthy" of what is, currently, the public's credit but for private gain.

Grayce , October 18, 2019 at 11:07 am

if they [governments] create too much you will get inflation
Is this true, or is it an economist's assumption? Here's the other thought:
Capitalism embraces borrowing for investment. Real estate development is an example. Borrowing involves an assumption of paying back more than was borrowed, but at a future date. When that future date arrives, it is in the borrower's best interest if the face value dollars are wroth less in spending power that the face value of the loan. You stated that, but the link to inflation is fuzzy.
Bank credit is a claim on future prosperity
Rather than the government's causality, and a nebulous prosperity, it may be the borrower's CFO who then decides to raise consumer prices to keep up with expenses. The borrowed dollars came from a banker-created asset, but the inflation is tied to a direct result similar to the so-called "wage-price spiral." In this case, the "interest-price spiral" that is not visibly tied to the supply of money.

Susan the other` , October 18, 2019 at 1:23 pm

I've got a new disconnect. I understand and appreciate how MMT works. It is the only way, imo, for a sovereign country to pay for the social costs of a good society. And, of course, the government does not charge itself interest, does not expect to be "paid back" at all. The tradeoff for the government is the betterment of society. So if your neighbor loans you $500 and you tell him you'll pay him back as soon as your check comes in and with some interest that seems fair bec. you're dealing with two private budgets. But when a licensed bank loans you money for a new house under the terms that you pay it back over 30 years with interests that amounts to triple the original cost of the house – then you are not dealing as one private person to another. You are then dealing with usury. Made legal by the private financial industry. This private industry does not use its own money – it uses the government's money by a computer click. And the government then lets it profiteer on this tiny transaction of apples and oranges to the degree that over time the money "earned" by the private bank accumulates and topples the steady state of the economy. At that point there's no place left to invest that "private" profit and the whole financial system goes haywire in a panic not to "lose" money. Money that should never have been given to them in the first place. It's an oxymoron – demanding that money be paid back with interest when it's not your money in the first place and you do nothing to stabilize your profligate profiteering. Nothing. Just a thought.

Synoia , October 18, 2019 at 2:49 pm

Zimbabwe found it all too easy to create so much money they caused hyper-inflation.

Yes, after destroying their Ag Industry, and having no Ag products to export, because Mugabe and his party assumed all the white farmers just sat around drinking beer while the dark farm workers did all the work.

After Mugabe took the land, there was no collateral for the farmers to get loans for the next planting season.

Who knew that managing the farm was so much work? /s

John k , October 18, 2019 at 2:55 pm

Inflation in Zimbabwe first came from shortages, especially food, as things looted rhe country of 4x and mismanaged the economy, like farm price controls under cost of production.
Historically shortages cause high inflation.

Burns , October 18, 2019 at 6:45 am

"In her op-ed, Koshgarian acknowledged that remaking the U.S. military as a truly 'defense-based institution, rather than a war machine and A.T.M. for private contractors, will require major changes.'"

Interesting. Beyond cost cutting, what exactly would it take to remake the military into a true defense-based institution ? How would assets be deployed? What weapons systems would be prioritized and ultimately receive funding? What doctrines would need to change to flip from an offensive mindset to a defensive mindset? What alliances would we maintain and what alliances would we discard?

I see that the article offers some examples, but I think crafting a progressive foreign policy would entail answering these kinds of more fundamental military questions. Cost cutting is a laudable goal but it strikes me that there's much more to it if real transformation is desired.

Lord Koos , October 18, 2019 at 2:11 pm

aybe ask Russia – their military policy is based on defensive posture rather than offensive.

Arnold , October 18, 2019 at 7:09 am

As a civil servant working for the Department of Defense, I can tell you that this would be a difficult shift in priorities for Congress to accept. It all comes down to the defense industry political donations they receive year after year, and the jobs the defense industry provides their constituents (no matter how meager or sub-optimal). Since defense spending is basically this nation's sole industrial policy, I think that finding employment for displaced workers (whether defense civil servants or contractors) is the biggest hurdle to address; a green new deal would solve the problem. We'd also need political campaign reform to force Congress off of the teet of defense industry political contributions.

Phacops , October 18, 2019 at 8:12 am

Finding employment for displaced defense civil servants or contractors? We've done that before . . . we tell them to train for the jobs of the future as we did for manufacturing workers and leave it at that. The same goes for the parasites working in health insurance companies, pharmacy benefit management and healtcare administration when M4A becomes a reality.

I have no sympathy for those people nor care for their well being as they deliberately, and with malice aforethought, make life meaner for us all.

John Wright , October 18, 2019 at 9:27 am

I remember when the defense/aerospace industry collapsed in Southern California in the early 1970's as the Vietnam war was winding down.

Tech jobs were scarce.

The political sphere is well aware of potential job loss due to defense cutbacks.

I have mentioned before, the relatively liberal CA Senator Barbara Boxer fought to preserve Mare Island Naval Shipyard, in Vallejo, CA, when it was slated to be shut down in the 1990's.

One could suggest that Vallejo has not fully recovered.

It is a tragedy of immense proportions, as I believe a future historian will remark that the USA, a nation that in its 200 + year history had only one large deadly war on its soil (the internal Civil War), re-titled its WWII "War Department" as "Defense Department" and then consumed tremendous resources in its purported defense for the next 70+ years.

A recent discussion with someone, that I regard as a "Northern California Liberal", about Trump's pullout of Syria further re-enforced that the resistance to ANY change in the MIC in the USA is formidable.

He was sure that Trump would be deservedly impeached because he was pulling out of Syria and abandoning our allies, the Kurds.

And he is old enough to remember Vietnam.

The USA news media and entertainment industries (big sports/Hollywood) are fully on board with the righteous USA "war is good" meme.

Given how the USA economy has restructured much employment and lifelihoods in costly sectors (finance, education, medicine, military) it is difficult for me to see how there would be political will to downsize the military to any extent as "good paying" jobs of politically powerful people would be lost.

Many of the manufacturing jobs have been moved overseas.

It is far easier to "kick the can down the road".

Off The Street , October 18, 2019 at 11:21 am

There is some hope for policy redirection in the Administration's recent Turkey-Syria-Kurd action. If there really is a shift away from foreign nation building and away from endless wars over endless enmities, then that could lead to redirection and reduction of military budgets. Watching the defenders of those engagements fall all over themselves recently has reconfirmed my notion that they are not acting in the best interests of their constituents. Meanwhile, the sun rose today.

xformbykr , October 18, 2019 at 7:38 am

The current defense spending and growth of national debt
more or less "prove" the validity of MMT. This has supported the channeling of resources and energy into military activity (and profits for enterprizes). Something similar is happening with healthcare; maybe it's inelastic
demand. (The similar something is ever-increasing costs.)
Healthcare at the moment seems to be outside of
the scope of current uses of MMT. But there are major
cost-control issues with it nonethess.
In what direction will things head if healthcare is
swept under the government MMT umbrella in the form of medicare for all? Will the government negotiate prices
with providers (hospitals, staff, pharma)? Certainly military procurement is no leading light.

Steve Ruis , October 18, 2019 at 8:17 am

While cutting the bloated Pentagon's budget is a very good idea, why is no one talking about the fringe benefit that is employer provided healthcare? I do believe a sizable fraction of folks on private insurance (maybe 40%?) get their health coverage through a fringe benefit from their employer. If that coverage is no longer necessary under universal coverage, it seems contractually that the money spent on the fringe benefit should go to the employees. That money is enough to pay for their insurance under universal coverage, so the employer pays it to the employee, the government taxes part of that to pay for the universal healthcare and everyone is better off. The employee, due to savings in the system, ends up with more money in pocket. The employer is out from under the ever increasing costs of the fringe benefit (plus can now claim to be paying higher salaries), and, well, the insurance companies are left behind to pick up "expanded coverage" for those wanting to pay for it.

This and "defense" spending cuts could pay for the whole system easily, no?

NotTimothyGeithner , October 18, 2019 at 8:57 am

The relative value of small business based jobs would increase with a functional health care system. There would be an outflow of employees from jobs with healthcare benefits.

With single payer, looking for a less stressful job becomes an alternative. Big employers know this.

rd , October 18, 2019 at 5:35 pm

It also means people may retire earlier if they don't need their employer-provided health insurance.

Health insurance becomes a minor consideration in selecting which employer to work for.

Companies and state/local governments that provide health care coverage in retirement should see their liabilities for that plummet as healthcare costs drop and public insurance improves.

inode_buddha , October 18, 2019 at 10:11 am

What contract? Unless you're in a union you don't have one.

HotFlash , October 18, 2019 at 11:36 am

Medicare for all makes self-employment, gig employment, and starting/running a small business much less terrifying.

Grayce , October 18, 2019 at 12:14 pm

COULD employers give the surplus to employees?
Technically, yes.
WOULD employers give the surplus to employees?
Not in this age of activist stockholders seeking new sources of "revenue." Everywhere. Benefits are simply a "cost." Human Resources is a "cost center." Defined benefits that averaged out the risk among many have segued to defined contribution that is no more than a tax-abated savings account. Risk has monetary value, but risk invisibly is shifting more and more to the individual.

Jeffersonian , October 18, 2019 at 8:37 am

After the last Democratic debate, it is safe say anti-war Progressivism is dead. Everyone was frothing at the mouth to prove how much they care for the Kurds, and our nation's honor, and that we should stay in the ME. Except Tulsi, but her response fell flat with the audience, and judging by my Left friends/family on Facebook, fell flat with them too. Having the same position as Trump is a death sentence. My faith in my fellow citizens is at quite a low ebb.

Grayce , October 18, 2019 at 12:19 pm

Cheer up. No matter what you used to think of Lindsay Graham, he is setting the pace for a representative to think for him/herself. Commentators reported surprise that he was "formerly in Trump's corner." Think about how easily we accept that the future is secured by a majority in either house. The outrageous president is inspiring elected Republicans to analyze issues (imagine!). Even if it is cold and calculated to influence their own voters, let's begin to applaud and encourage those who seem to think for them/ourselves.

Carl , October 18, 2019 at 8:45 am

We don't suffer from a lack of ideas in this area; no, we lack the ability (political will) to accomplish it. Thus, another exercise in mental masturbation.

notabanktoadie , October 18, 2019 at 11:17 am

we lack the ability (political will) to accomplish it. Carl

A Citizen's Dividend would be the camel's nose under the tent since the less wasted by government, the more that could be distributed to citizens to counter price deflation.

And it's only justice that all fiat creation, beyond that created for government to spend for the general welfare, be in the form of an equal Citizen's Dividend.

Carl , October 18, 2019 at 1:15 pm

Give me a shout if that ever happens. I'll be over in Europe enjoying low cost, high quality healthcare and not going bankrupt to pay for it.

notabanktoadie , October 18, 2019 at 1:55 pm

Funny you should mention Europe since an equal Citizen's Dividend for all Euro zone citizens would be a way to eliminate austerity that even Germany might not object to since Germans would receive it too.

Carl , October 18, 2019 at 6:44 pm

For example, Italy gives the unemployed 500 euros per month and tries to find them any sort of job. I think you're a little behind. But by all means, keep tilting at windmills.

Amfortas the hippie , October 18, 2019 at 1:15 pm

i was just thinking about that this am while finishing my fence like in alaska.
i figger that after 40+ years of declining or stagnant wages, a majority of us are owed some frelling back-pay.
but "dividend" works just as well.

notabanktoadie , October 18, 2019 at 2:13 pm

a majority of us are owed some frelling back-pay. Amfortas the hippie

The Citizen's Dividend would vary as required to counter price deflation but during the period when the banks are progressively de-privileged, it would have to be quite high to provide for the conversion of bank deposits to fiat deposits at the Central Bank – with the banks, by necessity, having to borrow the needed fiat from citizens.

notabanktoadie , October 18, 2019 at 2:22 pm


Or sell their assets to citizens at a discount.

In other words, a Citizen's Dividend PLUS de-privileging the banks can easily be a means to re-distribute wealth.

Carl , October 18, 2019 at 6:46 pm

Oh please, in what universe is this going to actually happen? You sound like you're running for office.

rd , October 18, 2019 at 10:08 am

Its still the wrong set of arguments. The problem in the US is not that Medicare-for-All would require new taxes that need funding. The problem is that the US spends twice per capita on healthcare what the average OECD country spends. The US spends more public tax money on healthcare per capita than Canada does, and Canada insures the entire population.

We can pay for our entire military budget as it exists if we simply drop our per capita healthcare spending to less than what Switzerland pays. Name one other thing that costs more in the US than in Switzerland.

Americans simply cannot comprehend how exorbitantly expensive and unequal the US healthcare system is compared to the rest of the developed world.

Mike , October 18, 2019 at 2:33 pm

While I gladly accept the results of these surveys, I question the reasons they seem to have garnered from the public. To most citizens, lower taxes mean much more than non-aggresive foreign policy and peaceful diplomacy. If the question was phrased in such a way that respondents were replying to the lower cost AND the concomitant peace-oriented habits that should (would?) come from it, then it is an issue whether they agreed with both statements. Further, this reorientation of spending would have to be bully-pulpited quite strongly to educate the US as to its long-term benefits since most of us have been prepped to be anxious about foreign nations and the paranoia of saving us from the evil dictator "X". Oh, yes, peace should come, but compare the Syria brou-ha-ha to what would descend upon us when peace broke out. The elites won't disappear.

Adam Eran , October 18, 2019 at 5:18 pm

Bizarre. The question is: How can we afford something that's half as expensive as what we're already paying? I wouldn't expect that level of insanity from someone in a straitjacket yet it's a commonplace in these discussions.

Even worse: the argument that government is financially constrained. It's not "tax & spend," it can't be. Where would taxpayers get dollars to pay those taxes if government didn't spend them first?

So it must be "spend first & then ask for some back in taxes." This is how reality works. And what do we call the dollar financial assets left in the economy, not retrieved by taxes? a) The dollar financial assets of the citizens, i.e. their savings or (same thing) b) National 'Debt'

National 'Debt' is completely unlike household debt. It's like bank debt. If you have a bank account, that's your asset, but to the bank, it's a liability. It's the money they owe you. It's their debt.

Now imagine a mob of depositors marching down to the bank to demand it reduce the size of its debt (i.e. make their accounts smaller) Crazy? Yes, but that's the austerian line of talk.

Finally, the inflationistas: "If you just print money, you'll have [gasp][hyper-]inflation!" This is the finest quality bullshit, and people spout it practically without prompting. The truth: The Fed extended $16 – $29 trillion in credit to cure the frauds of the financial sector in 2007-8. I defy anyone to find a measurement of inflation that says there was any then.

Was there central-bank-run-amok inflation in the classical cases (Weimar, Zimbabwe). Nope. Not even there. Yes they did print lots of Deutchmarks and Zimbabwe currency, but only after a shortage of good occurred that actually caused the inflation. Just printing money, especially if there's spare capacity, does not cause inflation. You need a bidding war for some commodity that's become scarce (like oil in the '70s). So Weimar had the burden of war reparations, a balance of payments problem, and when they delayed sending some telephone poles to France, the French military shut down the German equivalent of Ohio (the Ruhr). Shortages led to the hyperinflation. Similarly, the Rhodesian colonists left Zimbabwe, which had previously fed itself, and food shortages led to the hyperinflation.

The Cato study of 56 hyperinflationary episodes in human history also validates the above. In *no* case did a central bank "run amok" and print too much to kick off the hyperinflation. Always the cost push of a shortage of goods drove it.

Carl , October 18, 2019 at 6:47 pm

Nicely said.

RubyDog , October 18, 2019 at 6:51 pm

Gosh, it's all so simple. We just need to take on the military industrial complex, the medical industrial complex, and our corrupt political system all at the same time.

TG , October 19, 2019 at 12:04 am

Researchers Detail How Slashing the Social Security and Medicare Budgets Could Pay for More Pointless Wars While Creating the Progressive Wall Street Bailouts Americans Want.

[Oct 05, 2019] Medicare Advantage is a hustle designed to allow for-profit corporations to suck up public dollars. For years, Republicans have shoveled money into Medicare Advantage plans and allowed them to offer benefits that traditional Medicare is forbidden from covering

Oct 05, 2019 |

EMichael , October 04, 2019 at 11:48 AM

They will allow trump to do anything he wants as long as he does things like this.

" Back
Trump's Executive Order is Backdoor Privatization of Medicare

run75441 | October 3, 2019 8:52 pm

"Trump's Executive Order is Backdoor Privatization of Medicare," Social Security Works, Nancy Altman, October 3, 2019

I had to search around for someone who is an expert on Medicare Advantage Plans and Original Medicare. Nancy is one of those experts....

"Medicare Advantage is a hustle designed to allow for-profit corporations to suck up public dollars. For years, Republicans have shoveled money into Medicare Advantage plans and allowed them to offer benefits that traditional Medicare is forbidden from covering. This is a ploy to push seniors into Medicare Advantage plans instead of traditional Medicare. Medicare Advantage is stealth privatization intended to undermine traditional Medicare, which is an effective, popular government program and therefore loathed by Republican ideologues.

Under the Trump Administration, the thumb on the scale has turned into an entire arm. They've been flooding seniors' inboxes with advertisements for Medicare Advantage. What these emails don't mention is that Medicare Advantage plans often have narrow networks, restricting which doctors and hospitals patients are allowed to use. Worse, a recent government report found tt Medicare Advantage plans improperly deny care "in an attempt to increase their profits." It's no surprise that older, seniors are more likely to drop Medicare Advantage plans.

Medicare Advantage plans are also a terrible waste of public dollars. They have overcharged Medicare by $30 billion in the past three years alone.

Today's executive order is yet another giveaway to the corporations that run Medicare Advantage plans. Ironically, the Trump Administration is framing the executive order as an attack on Medicare for All. In fact, the massive flaws of Medicare Advantage epitomize the need to get for-profit greed out of health care by improving Medicare and expanding it to cover all Americans.

Medicare, like Social Security, works. Republicans want to privatize both of them. We have to stop them and instead, expand both."

EMichael -> EMichael... , October 04, 2019 at 11:52 AM
"The President* Is a Blight, But Watch What the Conservative Movement's Up to Behind Him

They're coming for Medicare, folks.

Even while he's floundering and crimin' his way across the landscape, El Caudillo del Mar-a-Lago still needs watching -- not just because of his many offenses against the Constitution and against human decency, but also for all the standard Republican policy goals that he's putting within reach. For example, on Thursday, the president* signed an executive order that supposedly "improved" Medicare. Then he flew to Florida to lie about it in front of an audience of the elderly. Within the executive order is a poison pill the size of a horse's head. Check out Section 3.

Section 3: Providing More Plan Choices to Seniors. (a) Within 1 year of the date of this order, the Secretary shall propose a regulation and implement other administrative actions to enable the Medicare program to provide beneficiaries with more diverse and affordable plan choices. The proposed actions shall:....

That, dear friends, is pretty much the same plan that Paul Ryan, the zombie-eyed granny starver from the state of Wisconsin, spent years trying to slime into law. It is the first big step toward Ryan's lifetime goal of privatizing the Medicare system, which, as someone who has enjoyed its benefits for almost a year, I can tell you is a terrible idea. Look at all the little buzzing land mines in there. "Competition." "Market pricing." This thing even expands Medical Savings Accounts, a terrible idea that emerged in the 1990s and that Bill Frist was going to ride into the White House in 2000.

The president* is a blight and impeachment is the only cure, but the conservative project rolls merrily on. I'm not entirely sure he knew what he was signing, because he doesn't know anything about anything, but the people who find him useful do, which is why he'll be around for a while longer."

ilsm -> EMichael... , October 04, 2019 at 01:47 PM
top dems, all corrupt, one unhealthy and one [self identified] false minority.... what does one do about them?
EMichael -> EMichael... , October 05, 2019 at 07:14 AM
And things like this. Imagine the lives they are going to destroy.

"Here's How We Know the Supreme Court Is Preparing to Devastate Abortion Rights

There's no other reason for the justices to take up the Louisiana abortion case.

The Supreme Court agreed on Friday to hear June Medical Services v. Gee, a challenge to Louisiana's stringent abortion restrictions. There is very little doubt that the conservative majority will use this case to overrule 2016's Whole Woman's Health v. Hellerstedt, allowing states to regulate abortion clinics out of existence. In the process, the Republican-appointed justices will set the stage for the formal reversal of Roe v. Wade. The court's decision to hear June Medical Services came with the alarming announcement that it will also consider whether to strip doctors of their ability to contest abortion laws in court. These aggressive moves augur an impending demise of the constitutional right to abortion access. ....

Because the 5th Circuit refused to adhere to binding precedent, Louisiana's abortion providers asked the Supreme Court to step in and block the law. It agreed to do so -- but only by a 5–4 vote, with Chief Justice John Roberts joining the liberals. In dissent, Kavanaugh argued that the court should allow the law to take effect and force the doctors to seek admitting privileges once again. His opinion was a rejection of Whole Woman's Health, dismissing the reality that Louisiana, like Texas before it, was trying to shutter clinics, not help women.

Given Kavanaugh's refusal to abide by precedent, the outcome of June Medical Services likely depends upon Roberts. It is true that the chief justice voted to block the law while the clinics appealed to SCOTUS. But his vote is best understood as a reminder to lower courts that they cannot flout liberal precedent just because Kennedy is off the bench. Roberts did not want the 5th Circuit to overturn Whole Woman's Health on its own -- only the Supreme Court can reverse its own precedent. But Roberts dissented in Whole Woman's Health. And when the case comes squarely before him, he will probably follow his conservative instincts, overturn or hollow out Whole Woman's Health, and allow states to impose draconian regulations on abortion providers that obligate clinics to shut their door.

The clearest indication of Roberts' vote is the fact that the court scheduled June Medical Services for oral arguments. When an appeal presents no new question of law and is clearly resolved by precedent, SCOTUS sometimes issues per curiam summary decisions. That means the justices affirm or reverse a lower court ruling without oral arguments through a brief, unsigned order. They prefer to issue these decisions when six justices sign on, but that's not a rule, and the court has issued 5–4 summary reversals before."

[Sep 29, 2019] Shares of Healthcare Costs, 2018

Sep 29, 2019 |

anne , September 28, 2019 at 11:44 AM

May, 2018

Shares of Healthcare Costs, 2018


( $15,788) ( 56%) employer subsidy


( 7,674) ( 27) employee contributions
( 4,704) ( 17) employee out-of-pocket costs
------------- --------
( 12,378) ( 44) total employee cost and share

( 28,166) ( 100) total medical cost for a family of four under a preferred provider organization

anne -> anne... , September 28, 2019 at 11:54 AM

May, 2018

Shares of Healthcare Spending, 2018

( $8,257) ( 29%) physician

( 8,631) ( 31) inpatient
( 5,395) ( 19) outpatient

( 4,888) ( 17) pharmacy

( 995) ( 4) additional
------------- --------

( 28,166) ( 100) total medical cost for a family of four under a preferred provider organization

anne -> anne... , September 28, 2019 at 01:14 PM
Correcting link:

anne , September 28, 2019 at 11:47 AM

May, 2018

Milliman Medical Index

The total medical spending in 2018 for a typical family of four is $28,166. *

2001 ( 8,414) Bush
2002 ( 9,235)
2003 ( 10,168)
2004 ( 11,192)

2005 ( 12,214)
2006 ( 13,382)
2007 ( 14,500)
2008 ( 15,609)
2009 ( 16,771) Obama

2010 ( 18,074)
2011 ( 19,393)
2012 ( 20,728)
2013 ( 22,030)
2014 ( 23,215)

2015 ( 24,671)
2016 ( 25,826)
2017 ( 26,944) Trump
2018 ( 28,166)

* Average annual medical spending for a typical American family of four covered by an employer-sponsored preferred provider organization program

anne -> anne... , September 28, 2019 at 11:55 AM

May, 2018

Milliman Medical Index

The annual growth rate in medical spending for a family of four from 2017 to 2018 is 4.5%.

2001-2002 ( 9.8) Bush
2002-2003 ( 10.1)
2003-2004 ( 10.1)

2004-2005 ( 9.1)
2005-2006 ( 9.6)
2006-2007 ( 8.4)
2007-2008 ( 7.6)
2008-2009 ( 7.4)

2009-2010 ( 7.8) Obama
2010-2011 ( 7.3)
2011-2012 ( 6.9)
2012-2013 ( 6.3)
2013-2014 ( 5.4)

2014-2015 ( 6.3)
2015-2016 ( 4.7)
2016-2017 ( 4.3) Trump
2017-2018 ( 4.5)

[Sep 25, 2019] UK Labour Party plan for reducing drug prices includes public funding for research and having new drugs available as generics

Sep 25, 2019 |

anne , September 24, 2019 at 06:47 PM

Dean Baker @DeanBaker13

UK Labour Party plan for reducing drug prices includes public funding for research and having new drugs available as generics (patents in public domain). Maybe progressive Democratic presidential candidates can learn something

5:39 PM - 24 Sep 2019

[Sep 22, 2019] Sicko The truth about the US healthcare system The Independent

Sep 22, 2019 |


Sicko? The truth about the US healthcare system | The Independent <style amp-boilerplate>body{-webkit-animation:none;-moz-animation:none;-ms-animation:none;animation:none}</style> Sicko? The truth about the US healthcare system Michael Moore's new film is a damning indictment of the way the world's richest country looks after those who fall ill. Andrew Gumbel finds out whether his accusations are justified Cynthia Kline knew exactly what was happening to her when she suffered a heart attack at her home in Cambridge, Massachusetts. She took the time to call an ambulance, popped some nitroglycerin tablets she had been prescribed in anticipation of just such an emergency, and waited for help to arrive.

On paper, everything should have gone fine. Unlike tens of millions of Americans, she had health insurance coverage. The ambulance team arrived promptly. The hospital where she had been receiving treatment for her cardiac problems, a private teaching facility affiliated with the Harvard Medical School, was just a few minutes away.

The problem was, the casualty department at the hospital, Mount Auburn, was full to overflowing. And it turned her away. The ambulance took her to another nearby hospital but the treatment she needed, an emergency catheterisation, was not available there. A flurry of phone calls to other medical facilities in the Boston area came up empty. With a few hours, Cynthia Kline was dead.

We'll tell you what's true. You can form your own view.

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She died in an American city with one of the highest concentration of top-flight medical specialists in the world. And it happened largely because of America's broken health care system - one where 50 million people are entirely without insurance coverage and tens of millions more struggle to have the treatment they need approved. As a result, medical problems go unattended until they reach crisis point. Patients then rush to hospital casualty departments, where by law they cannot be turned away, overwhelming the system entirely. Everyone - doctors and patients, politicians on both the left and the right - agrees this is an insane way to run a health system.

When Elizabeth Hilsabeck gave birth to premature twins in Austin, Texas, she encountered another kind of insanity. Again, she was insured -- through her husband, who had a good job in banking. But the twins were born when she was barely six months pregnant, and the boy, Parker, developed cerebral palsy. The doctors recommended physical therapy to build up muscle strength and give the boy a fighting chance of learning to walk, but her managed health provider refused to cover it.

The crazy bureaucratic logic was that the policy covered only "rehabilitative" therapy - in other words, teaching a patient a physical skill that has been lost. Since Parker had never walked, the therapy was in essence teaching him a new skill and therefore did not qualify. The Hilsabecks railed, protested, won some small reprieves, but ended up selling their home and moving into a trailer to cover their costs. Elizabeth's husband, Steven, considered taking a new, better-paying job, but chose not to after making careful inquiries about the health insurance coverage. "When is he getting over the cerebral palsy?" a prospective new insurance company representative breezily asked the Hilsabecks. When Elizabeth explained he would never get over it, she was told she was on her own.

Everyone in America has a health-care horror story or knows someone who does. Mostly they are stories of grinding bureaucratic frustration, of phone calls and officials letters and problems with their credit rating, or of people ignoring a slowly deteriorating medical condition because they are afraid that an expensive battery of tests will lead to a course of treatment that could quickly become unaffordable.

Even when things don't go horribly wrong, it is a matter of surviving by the skin of one's teeth.

In Montana, Melissa Anderson can't find affordable insurance because she is self-employed - an increasingly common affliction. When her son Kasey came down with epilepsy two years ago, she was saved only by a recently introduced child health insurance programme specifically tailored to people who aren't poor but can't afford to pay monster medical bills. She herself remains uninsured for anything short of major care needs.

Over the past 15 years, the stories have become less about poor people without the economic means to access the system - although that remains a vast, unsolved problem - and more about the kind of people who have every expectation they will be taken care of. Middle-class people, people with jobs that carry health benefits or - as the problem worsens - people with the sorts of jobs that used to carry robust health benefits which are now more rudimentary and risk their being cut off for a variety of reasons.

This is the morass that Michael Moore has chosen to explore in his latest documentary, Sicko, which goes on release later this month. Moore spends much of the film demonstrating that there is nothing inevitable or necessary about a system that enriches insurance companies and drug manufacturers but shortchanges absolutely everyone else. His searching documentary looks at health care in France, Britain, Canada, and even Cuba - still regarded as a model system for the Third World.

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Moore has his share of ghoulishly awful stories. The film kicks off with an uninsured carpenter who has to decide whether to spend $12,000 (ฃ6,000) reattaching his severed ring finger or $60,000 to reattach his severed middle finger. Later on, Moore focuses on a hospital worker whose husband needed a bone marrow transplant to save him from a rare disease. The couple's insurance company refused to cover the transplant because it regarded the treatment as "experimental". The husband died.

Many more stories are collected in a newly published book called Sick: The Untold Story of America's Health Care Crisis, by Jonathan Cohn. A woman in California called Nelene Fox died of breast cancer after she, too, was turned down for a bone marrow transplant by her insurance company. In Georgia, a family whose infant son went into cardiac arrest were forced to take him to a hospital 45 miles away on their insurance carrier's orders. He survived, but suffered permanent disabilities that more prompt treatment might have averted. In New York, an infant called Bryan Jones - whose case was trumpeted all over the local media at the time - died of a heart defect that went undetected because his insurance company kicked him and his mother out of hospital 24 hours after his birth, too soon to carry out the tests that might have spotted the problem.

America's health system offers a tremendous paradox. In medical technology and in the scientific understanding of disease, it is second-to-none. Since doctors are better paid than anywhere else in the world, the country attracts the best of the best. And yet many, if not most, Americans are unable to reap the advantages of this. In fact, as The New York Times columnist Paul Krugman has argued, the very proliferation of research and high-tech equipment is part of the reason for the imbalance in coverage between the privileged few and the increasingly underserved masses. "[The system] compensates for higher spending on insiders, in party, by consigning more people to outsider status --robbing Peter of basic care in order to pay for Paul's state-of-the-art treatment," Krugman wrote recently. "Thus we have the cruel paradox that medical progress is bad for many Americans' health."

Having the system run by for-profit insurance companies turns out to be inefficient and expensive as well as dehumanising. America spends more than twice as much per capita on health care as France, and almost two and a half times as much as Britain. And yet it falls down in almost every key indicator of public health, starting, perhaps, most shockingly, with infant mortality, which is 36 per cent higher than in Britain.

A recent survey by the management consulting company McKinsey estimated the excess bureaucratic costs of managing private insurance policies - scouting for business, processing claims, and hiring "denial management specialists" to tell people why their ailment is not covered by their policy - at about $98bn a year. That, on its own, is significantly more than the $77bn McKinsey calculates it would cost to cover every uninsured American. If the government negotiated bulk purchasing rates for drugs, rather than allowing the pharmaceutical companies to set their own extortionate rates, that would save another $66bn.

Astonishingly, there hasn't been a serious debate about health care in the United States since Bill Clinton, with considerable input from his wife Hillary, tried and failed to overhaul the system in 1994. That, though, may be about to change as the 2008 presidential race heats up. Everyone acknowledges the system is broken. Everyone recognises that 50 million uninsured - including almost 10 million children - is unacceptable in a civilised society.

Even the old, classically American free-market argument - that "socialised" medicine is somehow the first step on a slippery slope towards godless communism - doesn't hold water, because in the absence of a functioning private insurance regime the government ends up picking up about 50 per cent of the overall costs for treatment anyway. The indigent rely on a government programme called Medicaid. The elderly have a government programme called Medicare. And perhaps the most efficient part of the whole system is the Veterans' Administration, a sort of NHS for former servicemen.

Rather like London and Paris in the 19th century, where the authorities belatedly paid attention to outbreaks of cholera once the disease started affecting the rich and middle classes, so the American health crisis may be coming to a head because of the kinds of people who are suffering from its injustices.

Corporate chief executives, for a start, are gagging under the ever-increasing costs of providing coverage to their employees. Starbucks now spends more on health care than it does on coffee beans. Company health costs, as a whole, are at about the same level as corporate profits. In a globalised world where US businesses are competing with low-wage countries such as India and China, that is rapidly becoming unacceptable.

That explains, perhaps, why the chief executive of Wal-Mart, Lee Scott, has made common cause with America's leading service sector union - more commonly a bitter critic of Wal-Mart's labour practices - in calling for a government-run universal health care system by 2012. It's going to be a tough battle. The insurance and pharmaceutical industries bankroll the campaigns of dozens of congressmen and have so far been brutally efficient in protecting their own interests. The Clintons were defeated in 1994 in part because of the power of the industry lobbies. Doing better this time will take singular political courage.

In the meantime, we will hear ever more crazy stories like the one told by Marijon Binder, a former nun in Chicago who ended up being sued by a Catholic hospital for $11,000 because her two-night stay for a heart scare was not considered a worthy charity case. Binder, who works as a live-in companion to a disabled old woman, wrote on all her admission forms that she had no insurance and, in her telling at least, was reassured the hospital would take care of her anyway.

After a year and a monstrous bureaucratic fight that went nowhere, a civil judge promptly absolved her of responsibility for her bill - a lucky outcome, for sure. Binder said: "The whole experience was very demeaning. It made me feel very guilty; it made me feel like a criminal." She is, though, alive and solvent. Not everyone in this system catches the same break.

[Sep 22, 2019] Does America have a "Health Care System" or a Medical Delivery System that does a lousy job of delivering Health?

Sep 22, 2019 |

Fred C. Dobbs , September 20, 2019 at 11:32 AM

Is America's Health Care System a Fixer-Upper
or a Teardown?
NYT - Margot Sanger-Katz - Updated September 20

Illustrations by Tim Enthoven (at the link)

To understand the competing Democratic health care plans, consider an elaborate home construction metaphor.

Imagine the United States health care system as a sort of weird old house. There are various wings, added at different points in history, featuring different architectural styles.

Maybe you pass through a wardrobe and there's a surprise bedroom on the other side, if not Narnia. Some parts are really run down. In some places, the roof is leaking or there are some other minor structural flaws. It's also too small for everyone to live in. But even if architecturally incoherent and a bit leaky, it still works. No one would rather be homeless than live in the house.

In Democratic politics, there is agreement that the old house isn't good enough, but disagreement about just how possible -- or affordable -- fixing it will be. The biggest fault line in the debate is between candidates who think our current system can be salvaged with repairs and those who think it should be torn down and built anew. Building a dream house eases the way to simplification, but it increases potential disruption and cost.

The Pelosi plan

The most limited Democratic plan, championed by House Speaker Nancy Pelosi, for example, would deal with the house's biggest structural issues. It would lower the cost of health insurance for more people and fix some glitches in Obamacare's design -- the home construction equivalent of patching the roof, fixing a saggy porch and repainting. Residents could remain in the house while such minor repairs take place. These changes would not cost a ton of money. The house would still be weird. There would still be some people without a place to live.

The Biden plan

The next tier of health care plans, like the one from Joe Biden, would go further. Mr. Biden, too, would patch the roof and upgrade the windows. But he'd also put on a big new wing: an expansion of the Medicare program that would allow more people to join, sometimes called a public option. Everyone living in the house can stay while the renovations take place, though there might be disruptions. It would cost more, more homeless people would now fit in, and some living in the weirder wings might move into the new addition. People would pay for housing through a mixture of taxes and rent.

There are a bunch of plans in this general category, including proposals from Michael Bennet, Steve Bullock, Pete Buttigieg, John Delaney, Julian Castro, Amy Klobuchar, Beto O'Rourke and Marianne Williamson. They differ, mainly, in how many people in existing wings are allowed to move into the new wing, and how large that wing will be.

The Sanders plan

Bernie Sanders wants to tear down the weird old house entirely and build his dream home. It would be enormous and feature many wonderful amenities. When done, there would be no homeless people at all, and everyone's bedrooms would look exactly the same. The weirdness would be gone. But the entire old house would be gone, too, which some people might miss, and there could be unanticipated cost overruns in the construction. Some people might not enjoy the aesthetics of a modernist villa. While no one would have to pay rent in exchange for housing there, most people would have to pay more in taxes so the government could maintain the property.

Several candidates have signed on, in whole or part, to the single-payer dream house approach, including Cory Booker, Tulsi Gabbard, Elizabeth Warren and Andrew Yang.

The Harris plan

Kamala Harris also wants to tear down the old weird house. But she doesn't want to make everyone live in identical bedrooms. Her dream arrangement involves more choices, but most of the basic architectural features would be very similar. She would eliminate nearly every part of the existing health insurance system, and set up a new universal Medicare program that includes options from private insurers. It's like a housing development with several slightly different model homes. The basic architecture and amenities would all be the same, but families would be able to choose some custom options, like paint color, countertops and bed linens. It would also be expensive, and everyone would still need to move.

The debate

At the debate last week, you heard arguments between the teardown candidates and the fixer-upper candidates about cost -- and about change. Tearing down your current house comes with risks that many candidates don't want to take on.

Although big changes to the health care system often garner strong support in surveys, Americans frequently also tell pollsters that they like their current insurance arrangements, and would dislike giving them up. The authors of some fixer-upper plans assume that only some people are looking for a change, while other candidates assume that, over time, nearly everyone will want to opt into a form
of government-run insurance.

You also heard a debate about fairness and choice. Giving all Americans access to the same housing arrangements means that no one will have to live in a cramped attic. But it also means that some family members will have to part with some of their favorite furniture. "Of the 160 million people who like their health care now, they can keep it," said Mr. Biden, of the virtues of his fixer-upper proposal. "If they don't like it, they can leave." By contrast, Ms. Warren emphasized the universal nature of a teardown approach: "We're going to do this by saying, everyone is covered by Medicare for all; every health care provider is covered."

The "Medicare for all" system envisioned by Mr. Sanders would cover more benefits than nearly any system in the world, but it would require everyone to have the same type of insurance, with no easy workarounds for patients who aren't satisfied. Ms. Harris's plan would allow more choice, allowing private plans to operate alongside the government system. But those tightly regulated products would not be allowed to differ nearly as much as plans that exist in today's system, and would also amount to a brand-new system.

The candidates also disagree on how people should finance their ambitions. The fixer-upper candidates, for the most part, favor a system in which most Americans would still need to pay some form of rent to live in the house. The teardown candidates think everyone's housing costs should be financed by taxes instead of direct payments.

A tax-financed system would mean big changes in who pays what for health care, and how. A system that preserves a mix of taxes, premiums and direct payments like deductibles would mean less rearranging of the financing of health care, and would probably require more modest tax increases.

This is only a metaphor, of course. There are many ways the health care system is not like a residence. But if you've ever renovated or built a home, you know the emotional and budgetary stakes. The health care system is personal to many Americans, just like their home. It's no surprise the debate has been so heated.

im1dc -> Fred C. Dobbs... , September 20, 2019 at 04:01 PM
"Is America's Health Care System a Fixer-Upper
or a Teardown?"

Do you recognize the 'assumption' in the title, the fallacy?

Does America have a "Health Care System" or a Medical Delivery System that does a lousy job of delivering Health?

If the DEMS just fix what we have then we will get more of the same, i.e., a massive transfer of money from the people either out of their wallets or from taxation to the MEDICAL-INDUSTRIAL-COMPLEX that puts its profit above all patient welfare.

Go ahead and ignore my comment, after all I am just a D.C.

Fred C. Dobbs said in reply to im1dc... , September 20, 2019 at 04:14 PM
Let's say America has a "Health Care System" that is a 'Medical Delivery System that does a lousy
job of delivering Health'. Does that work for you?

Ours is after all (& over all) an economic
system that puts profit first.

ilsm -> Fred C. Dobbs... , September 21, 2019 at 04:39 AM
I agree with im1dc, we dare not recognize the US' 'health care system' for what it is.

It is a sacred market, where Milton Friedman told us markets make efficiency and also make its participants "free to choose".

PPACA did nothing but keep the profits in the "free to choose" edict.

However, the worth value, price....) of efficiency and "free to choose" is only measured from the perspective of those profiting.

Lately, some observers have been observing!

One is Binyamin Appelbaum.

David Warsh has read hos recent book.

It is somewhat critical of "free to choose" and market efficiency idolatry.

Appelbaum has observed that markets for such things and saving your life or warriors are such that the participants with demand really cannot go anywhere else.

"Free to choose" to work for the demanders must assure the choosers can leave the market and not die or work at Burger King.

Fred C. Dobbs said in reply to Fred C. Dobbs... , September 21, 2019 at 07:26 AM
This is (mostly) just semantics.
im1dc -> Fred C. Dobbs... , September 21, 2019 at 08:58 AM
Fred, this is NOT "mostly semantics" imo.

That is b/c our 'Health Care System' prioritizes profit to providers over OUTCOMES, which includes FDA oversight and rule making.

The Federal Government does not protect patients it protects Corporations, especially Big Pharma, Big Device Makers, Big Medical Groups, and Big Hospitals.

States are no better either.

The CDC imo today is chiefly operating in the public's interest most of the time, but...there are cracks forming there too.

FTR, we have superb medical scientists and superb world class Physicians that are forced to live and work in a system that denigrates and punishes them if they prioritize patients and people over profits and power.

IOW, since this is an Economics Blog, the American Health Care System practiced today prioritizes Capital over the Welfare or Commonweal of The People.

For example the Cost-Benefit Analysis in a For Profit system that pays Health Care CEO's, et. al., millions a year decays, diverts, and disrupts Health Outcomes Analysis due to a built in Profit benefit that feeds Executives that do not provide actual health care patient benefits.

Remember Pharma Bro Shkreli's 5000% price increase on Daraprim from $13.50 to $750 per tablet and the insane price increase of the epinephrine autoinjector EpiPen the Corporate CEO of that Big Pharma is the daughter of a Congressman and a DEM.

Are you aware some scientists of the FDA and CDC said they could manufacture off patent medicines cheaply and make them available to the public through the FedGovt if allowed to do so, but were turned down b/c it was thought unseemly for the FedGovt to compete with Big Pharma's Big Profits?

IOW, we are capable of drastic changes to the American Health Care System, lower costs and better outcomes for more people, but are stymied at every turn b/c Congress won't allow it due to the myth that pure Capitalism is the better way.

You should think about it instead of slavishly following the past and its built-in fallacies, tendencies, deficiencies, and errors.

And when you do you will ultimately come to the conclusion that prioritizing People over Capital in actual Health Care is the way it ought to be in the USA. We could catch up with the rest of the world in delivering Outcomes that increase our Health and longevity.

Fred C. Dobbs said in reply to im1dc... , September 21, 2019 at 09:45 AM
It *is* semantics when you insist
that there is No System when clearly
there is a system, but one that you
don't like.

Extraordinary difficulty of starting
from scratch on a new one, or making
drastic mods to the one we've got
is why it's so difficult to get
where you want to be. Which
is why we have to do the
latter, not the former.

And not too satisfying.

Not quite as tough as repealing
the 2nd amendment, but right up there.

[Sep 09, 2019] Will NPR Now Officially Change Its Name to National Propaganda Radio? by Edward Curtin

The main achievement of neoliberal and imperial (warmongering) propaganda in the USA is that it achieved the complete, undisputed dominance in MSM
Pot Calling the Kettle Black: "The Kremlin’s propaganda and disinformation machine is being unleashed via new platforms and continues to grow in Russia and internationally. Russia seeks to destroy the very idea of an objective, verifiable set of facts as it attempts to influence opinions about the United States and its allies. It is not an understatement to say that this new form of combat on the information battlefield may be the fight of the 21st century."
Notable quotes:
"... Back in the 1960s, the CIA official Cord Meyer said the agency needed to "court the compatible left." ..."
"... The CIA therefore secretly worked to influence American and world opinion through the literary and intellectual elites. ..."
"... Then in 1977, Carl Bernstein wrote a long piece for Esquire – “The CIA and the Media” – naming names of journalists and media (The New York Times, CBS, etc.) that worked hand-in-glove with the CIA, propagandizing the American people and the rest of the world. ..."
Sep 08, 2019 |

Back in the 1960s, the CIA official Cord Meyer said the agency needed to "court the compatible left."

Right-wing and left-wing collaborators were needed to create a powerful propaganda apparatus that would be capable of hypnotizing audiences into believing the myth of American exceptionalism and its divine right to rule the world.

The CIA therefore secretly worked to influence American and world opinion through the literary and intellectual elites.

Frances Stonor Saunders comprehensively covers this in her 1999 book, The Cultural Cold War: The CIA And The World Of Arts And Letters, and Joel Whitney followed this up in 2016 with Finks: How the CIA Tricked the World’s Best Writers, with particular emphasis on the complicity between the CIA and the famous literary journal, The Paris Review.

By the mid-1970s, as a result of the Church Committee hearings, it seemed as if the CIA, NSA, FBI, etc. had been caught in flagrante delicto and disgraced, confessed their sins, and resolved to go and sin no more.

Then in 1977, Carl Bernstein wrote a long piece for Esquire – “The CIA and the Media” – naming names of journalists and media (The New York Times, CBS, etc.) that worked hand-in-glove with the CIA, propagandizing the American people and the rest of the world.

It seemed as if all would be hunky-dory now with the bad boys purged from the American “free” press. Seemed to the most naïve, that is, by which I mean the vast numbers of people who wanted to re-stick their heads in the sand and believe, as Ronald Reagan’s team of truthtellers would announce, that it was “Morning in America” again with the free press reigning and the neo-conservatives, many of whom had been “converted” from their leftist views, running things in Washington.

... ... ... Lansing’s July 10, 2019 testimony before the House Appropriations Sub-Committee on State, Foreign Operations and Related Programs: “United States Efforts to Counter Russian Disinformation and Malign Influence.”

Here is an excerpt:

USAGM provides consistently accurate and compelling journalism that reflects the values of our society: freedom, openness, democracy, and hope. Our guiding principles—enshrined in law—are to provide a reliable, authoritative, and independent source of news that adheres to the strictest standards of journalism…

Russian Disinformation. And make no mistake, we are living through a global explosion of disinformation, state propaganda, and lies generated by multiple authoritarian regimes around the world. The weaponization of information we are seeing today is real. The Russian government and other authoritarian regimes engage in far-reaching malign influence campaigns across national boundaries and language barriers.

The Kremlin’s propaganda and disinformation machine is being unleashed via new platforms and continues to grow in Russia and internationally. Russia seeks to destroy the very idea of an objective, verifiable set of facts as it attempts to influence opinions about the United States and its allies. It is not an understatement to say that this new form of combat on the information battlefield may be the fight of the 21st century.

Then research the history of Radio Free Europe/Radio Liberty, the Voice of America, Radio and Television Marti, etc. You will be reassured that Lansing’s July testimony was his job interview to head National Propaganda Radio.

Edward Curtin writes, and his writing on varied topics has appeared widely over many years. He writes as a public intellectual for the general public, not as a specialist for a narrow readership. He believes a non-committal sociology is an impossibility and therefore sees all his work as an effort to enhance human freedom through understanding. His website is

[Sep 07, 2019] Private Equity and Surprise Medical Billing naked capitalism

Notable quotes:
"... By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow. ..."
"... The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck. ..."
"... Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye. ..."
"... A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi] ..."
Sep 06, 2019 |

September 6, 2019 by Jerri-Lynn Scofield By Eileen Appelbaum and Rosemary Batt Originally published at The Institute for New Economic Thinking website

Surprise medical billing has become a critical issue facing Americans across the country because of purposeful corporate practices designed to increase profits. As hospitals have outsourced emergency rooms and other specialty care to reduce costs, private investors have bought up specialty physician practices, rolled them into powerful national corporations, and taken over hospital emergency services. The result: large out-of-network surprise bills. The hidden actors: Leading private equity firms looking for 'outsized' returns.
Surprise medical billing made headlines in 2019 as patients with health insurance found themselves liable for hundreds or even thousands of dollars in unforeseen medical bills. When patients with urgent medical problems go to an emergency room (ER) or are treated by specialty doctors at a hospital that is in their insurance network, they expect that the services they receive will be 'in-network' and covered by their insurance. But often a doctor not in their insurance network is under contract with the hospital and actually provides the care. When this happens, patients are stuck with unexpected and sometimes unreasonably high medical bills charged by these 'out-of-network' doctors. This typically occurs when the hospital has outsourced the ER or other specialized services to a professional staffing firm or a specialty doctors' practice. This problem has exploded in recent years because hospitals are increasingly outsourcing these services to cut costs.

And more and more patients are faced with surprise medical bills -- adding substantially to the already impossible medical debt that working people face. Hospital outsourcing of emergency, radiology, anesthesiology, and other departments has provided an opening for physician practices to operate these services as independent organizations. Initially, hospitals outsourced these services to small, local doctors' groups

But over the past decade, private equity firms have become major players -- buying out doctors' practices and rolling them up into large corporate physician staffing firms that provide services to outsourced emergency rooms, anesthesiology and radiology departments, and other specialty units. By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow.

Private equity firms also own two of the three largest emergency ambulance and air transport services – another major source of surprise medical billing. Private equity ownership matters because the business model of private equity firms is to use a lot of debt in a leveraged buyout of companies they acquire and then extract as much cash as possible out of them in order to pay down the debt and reward their investors with 'outsized returns' that exceed stock market gains. They can be thought of as for-profit corporations on steroids. Buying up specialty practices is financially attractive because there is a large and growing demand for outsourced doctors, and out-of-network doctors can command a substantial premium for their services.

Emergency rooms and certain medical services provided in hospitals are not really part of a competitive 'marketplace' because patients in emergency medical situations rarely have a choice: they need immediate medical care and cannot 'shop around' for an in-network trauma doctor or radiologist.

Thus, surprise bills are difficult to avoid if patients face a medical emergency and must go to the ER or if they are hospitalized and require access to specialty medical services. How Widespread is Surprise Billing and Why Has It Grown?

Surprise medical billing is exacerbating the already serious problem of medical debt in this country, which is a leading cause of bankruptcy for American families. [i] And surprise billing is growing rapidly. Forty percent of Americans surveyed by the Kaufman Family Foundation in April, 2019, reported receiving an unexpected medical bill; and 20 percent of those surveyed said it was due to out-of-network charges – or surprise billing. [ii] A study by health researchers at Stanford University, for example, examined fees charged to patients with private insurance who were treated by the emergency department of a hospital. They reviewed 13.6 million trips to the ER that occurred over the period 2010 to 2016. About a third (32.3 percent) of these trips in 2010 resulted in a surprise medical bill. But by 2016, that figure had increased to 42.8 percent. That is, more than 4 in 10 trips to the ER ended with patients getting a surprise medical bill. [iii]

For in-patient stays, surprise billing rose from 26 percent to 42 percent, and the average costs per patient also jumped from $804 to $2,040. At this rate of increase, the estimated percent of hospital visits resulting in a surprise bill would be 48 percent in 2019 – or almost one half.

The study also found that in 2016, 86% of ER visits and nearly 82% of hospital admissions incurred surprise ambulance service bills. Similarly, another 2019 study found that patients who are admitted to a hospital from the ER are much more likely to receive an out-of-network charge -- as many as 26% of admissions from the emergency room were found to include a surprise bill. The study also found that 38 percent of Americans are 'very worried' and another 29 percent are 'somewhat worried' about being able to afford surprise medical bills.

People particularly vulnerable to these charges are those with coverage from large employers that are self-insured. And vulnerability also varied by region, with Texas, New York, Florida, New Jersey, and Kansas having higher rates of surprise billing; and Minnesota, South Dakota, Nebraska, Maine, and Mississippi having lower rates. [iv] While large surprise medical bills are typically associated with doctors in the ER or in specialties such as radiology, anesthesiology, or critical care units such as neo-natal, burn, or trauma centers, other out-of-network physicians may also issue surprise bills. For example, those who assist a patient's doctor in a procedure or hospitalists who check on patients during hospital stays can also charge separately for their services.

The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck.

The patient's own in-network surgeon sent a bill for $133,000, but accepted a fee of $6,200 negotiated with the insurance company. The out-of-network assistant surgeon is seeking full payment of his charges. This is a particularly egregious example, but surprise bills for a few thousand dollars are not uncommon. [v]

The problem of surprise billing has grown substantially in recent years because hospitals have been under financial pressure to reduce overall costs and have turned to outsourcing expensive and critical services to third-party providers as a cost-reduction strategy. Outsourcing is not new, as hospitals began outsourcing non-medical ancillary services such as facilities management and food services in the 1980s, in response to a round of structural changes in government financing.

By the 1990s, hospitals were experimenting with the use of independent 'hospitalists' to care for patients between rounds by the local admitting doctors who had a hospital affiliation. Hospitalists' numbers increased over the next two decades as hospital staffing firms grew and provided a range of temporary or short-term professionals to fill shortages in nursing, technical, or clinical positions. [vi]

Recent outsourcing, however, has expanded to critical care areas – emergency rooms, radiology, anesthesiology, surgical care, and specialized units for burn, trauma, or neo-natal care. Now hospitals contract with specialty physician practices or professional physician staffing firms to provide these services – even if the patient receives treatment at a hospital or at an outpatient center that is in the patients' insurance network. According to one study, surprise billing is concentrated in those hospitals that have outsourced their emergency rooms. [vii] A recent report found that almost 65 percent of U.S. hospitals now have emergency rooms that are staffed by outside companies. [viii] Hospitals and healthcare systems have accelerated their outsourcing of critical care areas since 2010 in part due to declines in Medicaid and Medicare reimbursements and to incentives under the Affordable Care Act to reduce costs and improve care quality. [ix]

At the same time, on the supply side, hospitalist companies were merging and buying up practices of specialists employed mainly in hospitals. Hospitalist companies evolved into physician staffing firms and expanded to include staffing for emergency rooms (ERs), anesthesiology and radiology departments, and burn and neonatal intensive care units in hospitals across the country. The business case for hospitals to outsource was straightforward. Emergency rooms are a major point of entry for patients who are admitted to hospitals, and thus, a major conduit for the in-patient hospital stays that are critical for hospital revenue generation. But they are costly and difficult to manage as they must be adequately staffed on a 24/7 basis regardless of patient flow, which is unpredictable. Outsourcing the management, staffing, and billing of ER services shifts these management problems and the risk of underpayment for these services to the staffing firm or a specialty doctors' practice. Hospital emergency rooms cannot turn patients away if they lack adequate insurance coverage or any insurance at all; they must treat all patients. Emergency departments make money on ER visits of patients with commercial insurance, but lose money on those with Medicare or Medicaid, and see very high losses when patients have no insurance. [x]

Private Equity's Business Model: Its Role in Outsourcing and Consolidating Specialty Services Private equity firms have played a critical role in consolidating physicians' practices into large national staffing firms with substantial bargaining power vis-เ-vis hospitals and insurance companies. They have also bought up other emergency providers, such as ambulance and medical transport services. They grow by buying up many small specialty practices and 'rolling them up' into umbrella organizations that serve healthcare systems across the United States. Mergers of large physician staffing firms to create national powerhouses have also occurred. As these companies grow in scale and scope and become the major providers of outsourced services, they have gained greater market power in their negotiations with both hospitals and insurance companies: hospitals with whom they contract to provide services and insurance companies who are responsible for paying the doctors' bills. Hospitals have consolidated in order to gain market share and negotiate higher insurance payments for procedures.

Healthcare costs have been driven up further by the dynamics associated with payments for out-of-network services. As physicians' practices merge or are bought out and rolled up by private equity firms, their ability to raise prices that patients or their insurance companies pay for these doctors' services increases. The larger the share of the market these physician staffing firms control, the greater their ability to charge high out-of-network fees. The likelihood of surprise medical bills goes up, and this is especially true when Insurance companies find few doctors with these specialties in a given region with whom they can negotiate reasonable charges for their services. The design of the private equity business model is geared to driving up the costs of patient care. Private equity funds rely on the classic leveraged buyout model (LBO) in which they use substantial debt to buyout companies (in this case specialty physician practices as well as ambulance services) because debt multiplies returns if the investment is successful. They target companies that have a steady and high cash flow so they can manage the cash in order to service the debt and make high enough returns to pay their investors 'outsized returns' that exceed the stock market. [xi]

Emergency medical practices are a perfect buyout target because demand is inelastic, that is, it does not decline when prices go up. Moreover, demand for these services is large – almost 50 percent of medical care comes from emergency room visits, according to a 2017 national study by the University of Maryland School of Medicine, and demand has steadily increased. [xii]

PE firms believe they face little or no downside market risk in these buyouts. Private-equity owned companies differ from publicly traded for-profit chains not only in their greater use of debt, but also because the private equity firm, via the general partner of the investment fund it sponsors, makes all investment decisions on behalf of the investor shareholders. Investors commit capital to a PE-sponsored fund, typically for 10 years, and have no say in investment decisions. Thus, the PE general partner's power is concentrated and largely unaccountable, as investors cannot 'exit' or sell their shares if they are dissatisfied – unlike shareholders in publicly traded corporations. [xiii]

In addition, PE firms charge their portfolio companies additional 'advisory fees' and 'transactions fees' that can amount to millions of dollars over time. And because PE owned companies are not publicly traded on the stock exchange, they are not required to file a detailed report to the Securities and Exchange Commission (SEC) the way that publicly traded companies must do. Their activities and their financial transactions are largely hidden from the public eye, despite the fact that they receive substantial taxpayer funding from Medicare and Medicaid for their services, though not for surprise charges. Two private-equity owned physician-staffing firms dominate the market for outsourced doctors' practices -- Envision Healthcare, owned by KKR with 69,300 employees, and TeamHealth owned by Blackstone Group with 20,000 employees. KKR also is a major owner (along with other private equity firms) of AirMedicalGroup Holdings -- one of the nation's three largest ambulance and air transport companies.

We also showcase private equity owned Air Methods medical transport company. These examples help illuminate how and why private equity firms have become national powerhouses in the provision of professional healthcare services and why their activities and those of other private equity firms in this sector are leading to higher healthcare costs for patients and the industry as a whole.

Envision Healthcare
Envision Healthcare today is the result of fifteen years of private equity transactions in buying up and consolidating emergency ambulance and specialty physicians' practices. It was formed in 2005 when private equity firm Onex took over two companies -- American Medical Response (AMR) and EmCare -- and merged them. In and out of private equity ownership since 2005, Envision most recently was acquired by KKR in October, 2018 in a public to private leveraged buyout worth $9.9 billion. Its sprawling organization employs tens of thousands of healthcare professionals; and it supplies doctors in 774 physician practices to hospitals and ambulatory surgical centers throughout the United States. It provides ER doctors, anesthesiologists, radiologists, hospitalists, and other specialists covering intensive care, medical, neo-natal, pediatrics, psychiatric, skilled nursing, rehabilitation, and other inpatient units.

Its outpatient ambulatory surgical arm (AMSURG) provides trauma and acute care general surgery in 260 facilities in 35 states. [xiv]

Between 2005 and 2018, Envision provided two types of emergency medical services: an ambulance and medical transport business through American Medical Response (AMR) and emergency physician staffing through EmCare Holdings.

Today, Envision focuses on physician staffing services as it sold the ambulance and transport business in a $2.4 billion leveraged buyout in 2018 to another private equity consortium that still includes KKR (as we detail below). The prior ownership patterns of AMR and EmCare were similar. American Medical Response was listed as a publicly traded company as of August 1992; and in February, 1997, it was acquired by ambulance company MedTrans, a subsidiary of Laidlaw International. At an undisclosed date between 1997 and 2005, PE firm Peak Capital invested an undisclosed amount in the company. Like AMR, EmCare Holdings was acquired by Laidlaw International in the summer of 1997 and subsequently received an undisclosed amount of investment from PE firm Peak Capital.

Emergency physician practices figured prominently among EmCare's 10 acquisitions and 17 sister physician staffing and management firms. [xv] In December 2005, just months after acquiring and merging AMR and EmCare, Onex brought Envision Healthcare to the public market via an IPO in which it retained a majority of the shares. Subsequent sales of shares left Onex with 31 percent of the company's equity at the time it was again taken private, this time by Clayton Dubilier & Rice with participation of PE firm Ardian through a $3.2 billion LBO in May 2011. An IPO in 2013 returned Envision Healthcare to the public market. The PE owners retained about two-thirds of the shares of the now-publicly traded company. The PE companies subsequently sold some of the stock. And in September 2017, two hedge funds – Starboard Value and Comex Management – took minority stakes in Envision Healthcare.

Between July 2006 and October 2018, Envision Healthcare acquired 39 companies. [xvi] Envision Healthcare bought out AMSURG in December 2016 after AMSURG failed in an attempt to acquire TeamHealth (described below). The deal brought together two seemingly complementary healthcare companies to form a single organization with pro forma market capitalization of $10 billion and an enterprise value including debt of approximately $15 billion. A little over $8 billion of this was new debt.

However, KKR contributed $5.57 billion to the deal, using $4.43 billion to retire Envision's prior liabilities and the remainder mainly as equity in the LBO.

Adding AMSURG's large chain of ambulatory surgical centers was supposed to make Envision Healthcare a dominant player across the outsourced medical services landscape – emergency room doctors, hospitalists, outpatient surgery, and ground and air ambulance. But integrating the two health care companies – with a combined 69,300 employees as of December 2017 – proved difficult for publicly traded Envision Healthcare. [xvii] Envision Healthcare appears to be extremely profitable, but its financials are murky, with no publicly available accounting of its transactions with each round of private equity buyouts. And under private equity ownership, when companies are taken private or pass from one private equity fund to another, there is no transparency.

Each private equity buyout, however, is typically accompanied by levering substantial debt on the target company, which must be serviced by managing for cash. Emergency medical services are attractive to private equity firms and are very lucrative because they throw off a lot of cash, and as noted earlier, demand is inelastic and the fees are not subject to competitive market pricing. The contracts negotiated between these physician staffing companies and hospitals also are not publicly available. Depending on how they are crafted, they may provide incentives to outsource even more ER departments, and in turn increase out-of-network billing. One Wall Street investor analysis, for example, highlights Envision's 'joint venture' model that raises serious questions.

A 2013 analysis by Deutsche Bank Securities described a 2012 joint venture between EmCare and the HCA Healthcare chain – with a history of private equity ownership between 2006 and 2011 and substantial PE ownership of shares following its 2011 IPO. HCA apparently agreed to give up directly charging for physicians' services and outsourced these services to EmCare in exchange for a 50-50 profit split once EmCare achieved a 13% margin threshold, according to the Deutsche Bank calculation. This allowed EmCare to " penetrate HCA's 160+ hospital portfolio more deeply with its physician offerings." As of 2014, EmCare valued its HCA joint venture at a net revenue of $124 million, with assets of $155 million and liabilities of $31 million, according to the company's SEC filing. The filing identified similar joint ventures with hospitals involving Evolution Health (also owned by Envision). [xviii]

Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye." [xix] Envision has come under heavy scrutiny for the huge out-of-network surprise medical bills it sends to ER patients.

A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi]


TeamHealth has also grown into a powerful national healthcare professional staffing company with 20,000 employees. It contracts with hospitals to provide doctors and other healthcare professionals as ER staff, anesthesiologists, hospitalists, and hospital specialists (OB/GYN, orthopedics, general surgery, pediatric services); and in post-acute care, ambulatory care, and behavioral health. [xxii] The company experienced successive rounds of private equity leveraged buyouts punctuated by IPOs that returned it to the public markets – only to be taken private again through another LBO. In 1999, private equity firms Cornerstone Equity Investors and Madison Dearborn Partners, with minority participation of Becken Petry O'Keefe and Company, acquired TeamHealth as a platform for a physician staffing company. According to PitchBook (an industry research and data firm), TeamHealth acquired an anesthesiology practice, a hospitalist company, and a health management business in its first two years. It made no further acquisitions until after it was acquired by the Blackstone Group in 2005 in a leveraged secondary buyout (in which one PE fund sells a company to another PE fund). TeamHealth made two more acquisitions between 2005 and 2009 – an emergency physician's group and a hospitalist company.

In 2009, Blackstone Group returned TeamHealth to the public market via an IPO, but retained possession of a majority of shares in the newly public company. Passage of the Affordable Care Act in 2010, with its promise of cost containment via capitated and bundled payments, spurred TeamHealth to go on a buying spree. Between 2010 and 2016, TeamHealth acquired 51 companies, mainly practices of emergency doctors and anesthesiologists and a few hospital management companies. One very large exception to this pattern was TeamHealth's 2015 acquisition of IPC Healthcare. [xxiii]

IPC Healthcare was a major hospitalist company. In its early years, it attracted four rounds of venture capital investments between 1998, when it was launched as IPC The Health Company, and 2002. In June 2002, IPC had an IPO and began its life as a publicly traded company. Between 2002 and 2009, IPC acquired 20 physician practices. Between 2010 and 2015, following passage of the ACA, it acquired 78 more. The companies acquired by IPC were overwhelmingly hospitalist companies with a smattering of doctor's practices in specialties such as geriatrics. [xxiv]

TeamHealth's acquisition of IPC in 2015 raised questions. There was no evident fit between TeamHealth's specialty physician practices and IPC's hospitalist companies. IPC was also in trouble with the Department of Justice, which in June 2014, had filed a civil lawsuit against the company for "knowingly engaging in systematic overbilling" for services billed to Medicare and Medicaid and other government health programs. Ultimately, TeamHealth paid $60 million plus interest to resolve these allegations. [xxv] This fueled speculation that TeamHealth, which had rebuffed AMSURG's attempt to acquire it, wanted this very large acquisition in order to protect itself from being taken over. TeamHealth's explanation was that it wanted IPC's expertise in participating in Medicare and Medicaid bundled payments programs. [xxvi]

In February 2017, Blackstone Group once again took TeamHealth private in a $6.1 billion leveraged buyout. Similar to Envision Healthcare, the financials of TeamHealth are murky. After many LBOs, its revenues, debt load, and financial stability remain unknown, as do the contracts it negotiates with the phyisician groups it has acquired and the hospitals it contracts with for services.

And like Envision, its billing practices are being scrutinized. The Yale researchers who investigated EmCare and found excessive use of surprise medical billing also examined TeamHealth's billing practices. They found that Blackstone owned TeamHealth has taken a somewhat different tack. It uses the threat of sending high out-of-network surprise bills for ER doctors' services to an insurance company's covered patients to gain high fees from the company as in-network doctors. In most cases, the researchers noted, TeamHealth emergency physicians would go out-of-network for a few months, then rejoin the network after bargaining for in-network payment rates that were 68 percent higher than in-network rates received by the previous ER doctors. [xxvii] While this avoids the situation of a patient getting a large, surprise medical bill for the services of ER doctors, it raises healthcare costs and premiums for everyone.

Emergency Ambulance and Air Transport Services

Emergency ambulance and air transport is also a lucrative target for private equity investment, which has fueled consolidation in this industry segment. Demand is inelastic – there is no competitive market pricing. And demand for air transport has grown considerably because many rural hospitals have closed or consolidated, leading to far longer distances for access to emergency care. Two of the three air transport companies that together control two-thirds of this US market are private equity owned – AirMedicalGroup Holdings and Air Methods. The third, PHI Air Medical, is privately owned. [xxviii]

Returning to the Envision story, recall that American Medical Response (AMR) was the ambulance service division that Envision spun off in 2018. Before the divestiture, however, AMR grew to a national powerhouse in the decade from 2007 to2017 through 12 acquisitions of ambulance and medical transport businesses and one air ambulance company7. In addition to these acquisitions, AMR has seven sister companies – mainly ambulance companies, including several air ambulance businesses. It was acquired in 2017 by air ambulance company, AirMedicalGroup Holdings (AMGH) -- owned by PE firms Ardian, Koch Equity Development, and KKR -- in a $2.4 billion leveraged buyout. With this acquisition, AirMedicalGroup now holds a leading position in emergency and medical transport across a range of transport modalities. [xxix] The acquisition merged the largest provider of ground ambulance services in the U.S. with a leading operator of medical helicopters, with over 320 locations in 38 states. [xxx] The combined entity creates the opportunity for KKR to substitute its more expensive medical helicopters for short trips previously done by AMR's ambulances. [xxxi]

Air Methods became private equity owned in 2017, when it was acquired by American Securities and Alpinvest Partners through a $2.5 billion public-to-private LBO. The company's air medical transport services operate out of over 300 bases in 48 states. [xxxii] The buyout came in response to pressure from activist hedge fund investor, J. Daniel Plants, founder of Voce Capital Management. Concerned about the bad publicity surrounding predatory charges by air ambulance companies, Plants wanted Air Methods to agree to be taken private by a PE firm in order to keep information about its billing practices out of public view. According to the hedge fund, Air Methods big price hikes created economic and political risks for the company. Going private would shield its financial documents from patients and insurers. The hedge fund was right to be concerned about Air Methods predatory billing practices. The average bill for being transported in one of its medical helicopters was $17,262 in 2009 and had risen to $40,766 in 2014. Air Methods calculates that it accounts for nearly 30 percent of total air ambulance revenue in the U.S. Its profit increased sevenfold from 2004 to 2014. [xxxiii]

In general, charges for out-of-network ambulance services are likely to be high. In the case of air ambulances, they are exceedingly high – not only due to the high costs of air travel, but especially because an estimated 69 percent of charges are out-of-network -- according to a 2017 US General Accountability Office (GAO) study of private insurance records for 2012-2017. That is, insured patients in these cases ended up being billed for most of the charge. The GAO study also found that the median price for helicopter service doubled between 2010 and 2014 – from roughly $15,000 to $30,000 per tri;p it also found that the average cost of an air ambulance trip is over $36,000. . [xxxiv] Another study by researchers at Johns Hopkins University found charges were likely to be – as they put it – sky high. The study found that air ambulance charges had risen substantially from 2012 to 2016, and in 2016 these charges ranged from 4 to 9 times higher than what Medicare paid for this service. Some of the largest providers had among the highest charges. Between 2012 and 2016, the median charge ratios (the charge divided by the Medicare rate) for the services increased by 46-61 percent. [xxxv]

Legislative Solutions

Some hospitals have attempted to solve the problem of surprise billing on their own by simply requiring all attending physicians in their hospitals to remain in-network – receiving payment from the insurance companies with whom the hospital has contracted. This has been the traditional approach used by hospitals in managed care networks. According to John Cascell, Senior Vice President of Managed Care at MemorialCare Health System in Fountain Valley, California, "Such stipulations were commonplace decades ago, but some experts say the practice slipped out of favor around 2000 as major physician staffing companies -- which tend to make more money when they're out of network -- gained market power." [xxxvi] MemorialCare, however, has retained this long-standing policy, which Cascell supports. The downside of this approach, however, is that it may shift bargaining power to insurance companies who will seek to set lower in-network payments for specialty services. In these cases, according to Cascell, MemorialCare takes a strong role in negotiating with insurance companies to maintain reasonable payments. [xxxvii]

More generally, the public, healthcare providers, insurers, and state and federal legislators recognize that individual solutions are only stop-gap measures and that no individual hospital can solve the pervasive problem of surprise medical billing on its own. Twenty-five states have passed legislation that aims to protect patients from surprise billing, but these laws do not fully cover all types of situations. Over seventy-five percent of Americans believe that the federal government should step in and protect them from surprise bills, according to a Kaufman Family Foundation April, 2019 national survey. The same survey found that 90 percent of Democrats, three-quarters of Independents, and 60 percent of Republicans favored federal legislation to protect patients. [xxxviii] Americans differ, however, in who they think should bear the costs of care. According to the Kaufman survey, about half say insurance companies alone should cover the costs of care (43 percent) while about half favor joint responsibility between providers and insurance companies (47 percent). [xxxix]

Two approaches to 'fixing' surprise medical bills have been put forward. One would benchmark the fees paid to out-of-network doctors to the negotiated fees received by in-network doctors in that region for the procedure performed or the service provided. This would have the effect of holding down health care costs by setting limits to what out-of-network physicians can charge. In the second approach, out-of-network doctors would immediately be paid a given amount by the patient's insurance company – possibly 125 percent of the Medicare payment or, alternatively, the median payment for that procedure or service in the geographic region – and could then take the insurance company to arbitration in an effort to collect the balance of the patient's bill.

The second approach has the potential to raise health care costs if arbitration panels award out-of-network doctors all or a major part of the fees they charge. This approach, which is favored by investor-owned physician staffing firms and by large physician practice groups, would further raise health care costs for consumers. Even if many of these physician practices became in-network doctors, as Envision now claims to be doing [xl] , the threat of going out-of-network remains. As the TeamHealth example illustrates, this allows physician staffing firms to negotiate high in-network rates that drive up premium costs for consumers.

In sum, there is growing concern over the pricing practices of companies like Envision, TeamHealth, AirMedicalGroup, and Air Methods -- leading emergency healthcare companies owned and operated by private equity firms. There is little oversight of the prices they charge, and evidence suggests that these companies are among those responsible for driving up health costs by taking advantage of the possibilities for surprise medical billing. But they are not alone, as private equity firms buy out medical services in specialties other than trauma and radiology and as large physician practices take a page from the PE playbook when setting fees. Reining in these charges is critical to efforts to slow the growth or even reduce health care costs.

[i] Mireya Villarreal. 2019. "Insurance Gap Leaves Patients on the Hook for Unexpected Hospital Bills." CBS News TMarch 18, 6:45 PM (last accessed August 17, 2019)

[ii] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. "KFF Health Tracking Poll – April 2019: Surprise Medical Bills and Public's View of the Supreme Court and Continuing Protections for People with Pre-Existing Conditions." Figure 13. Kaufman Family Foundation. April 24. (last accessed August 20, 2019)

[iii] Eric C. Sun, Michelle M. Mello, Jasmin Moshfegh, et al. 2019. "An Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals," American Medical Association JAMA Internal Medicine, August 12. (last accessed August 18, 2019)

[iv] Karen Pollitz , Matthew Rae , Gary Claxton , Cynthia Cox and Larry Levitt . 2019. "An Examination of Surprise Medical Bills and Proposals to Protect Consumers from Them." Kaiser Family Foundation . June 20. (last accessed August 16, 2019)

[v] Elisabeth Rosenthal. 2014. "After Surgery, Surprise $117,000 Medical Bill from Doctor He Didn't Know," New York Times , September 20. ; (last accessed August 12, 2019); Sun, Mello, Moshfegh, et al. 2019.

[vi] Mark A. Marinella. 2002. "Hospitalists – Where They Came From, Who They Are, and What They Do," Hospital Physician , May. (last accessed July 23, 2019) ,

[vii] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018. "Surprise! Out-of-Network Billing for Emergency Room Services in the U.S.," Yale University Working Paper , March. (last accessed August 1, 2019)

[viii] Mireya Villarreal. 2019.

[ix] Beckers Hospital Review. 2013. "Outsourcing is Exploding in Healthcare -- Will the Trend Last?" October 4. (last accessed August 25, 2019)

[x] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.

[xi] For a detailed explanation of the PE business model, see Chapter 2, Eileen Appelbaum and Rosemary Batt. 2014. Private Equity at Work: When Wall Street Manages Main Street , NY: Russell Sage Foundation Press.

[xii] Jeff Lagasse. 2017. "Nearly Half of Medical Care Comes from Emergency Rooms, Study Shows." (last accessed July 13, 2019).

[xiii] Rosemary Batt and Eileen Appelbaum. 2019. "The Agency Costs of Private Equity: Why do Limited Partners Funds Still Invest?" Academy of Management Perspectives. Forthcoming.

[xiv] Envision Physician Services.; (last accessed August 22, 2019)

[xv] PitchBook_EmCare_2019_08_10_14_18_43, EmCare Company Profile dated July 27, 2019.

[xvi] PitchBook_Envision_Healthcare_2019_08_10_16_06_31, Envision Healthcare Profile dated July 27, 2019; Brooke Sutherland. 2018. "It's the Great Health Care Buyout Shuffle," Think Advisor , June 11. (last accessed August 13, 2019)

[xvii] PitchBook. 2019. Envision Healthcare Profile dated July 27, 2019.

[xviii] Susannah Luthi. 2019. "In Battle Over Surprise Bills, Senate Ponders Requiring In-Network Rates." June 12. (last accessed August 10, 2019).

[xix] Susannah Luthi. 2019.

[xx] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.

[xxi] Michael J. de la Merced. 2018. "K.K.R. Said to Be Near Deal to Acquire Envision Healthcare," New York Times , June 10. ; Shelby Livingston. 2018. "UnitedHealth Hits Back at Envision over ER Billing Practices," Modern Healthcare , March 20. ; Senator Claire McCaskill's letter to Envision can be found here (last accessed August 2, 2019)

[xxii] TeamHealth. 2019. Our Company. (last accessed August 22, 2019).

[xxiii] PitchBook. 2019. Team_Health_Holdings_2019_08_09_17_21_39, TeamHealth Holdings Company Profile dated July 27, 2019.

[xxiv] PitchBook. 2019. IPC_Healthcare_2019_08_09_17_57_38, IPC Healthcare Company Profile dated July 27, 2019.

[xxv] U.S. Attorney's Office, Northern District of Illinois. 2014. "U.S. Files Lawsuit against IPC The Hospitalist Company, Alleges Overbilling of Federal Health Insurers for Physician Services," Department of Justice , June 17. ; M.L. McLaren. 2017. "$11M Whistleblower Award on TeamHealth $60M Overbilling Medicare & Medicaid at IPC Healthcare," Whistleblower News Review , February 27. (last accessed August 19, 2019)

[xxvi] Jason Carris. 2015. "TeamHealth Announces $1.6 Billion Acquisition of IPC Healthcare," The Hospitalist , August 4. ; Steven Ross Johnson. 2015. "Why TeamHealth Plans to Pay $1.6 billion for IPC Healthcare," Modern Healthcare , August 4. (last accessed August 16, 2019)

[xxvii] Zack Cooper, Fiona Scott Morton, and Nathan Shekita. 2018.

[xxviii] United States Government Accountability Office. 2019. "Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk," GAO, March. (last accessed August 25, 2019)

[xxix] PitchBook. 2019. American_Medical_Response_2019_8_10_13_21_18, American Medical Response Company Profile dated July 27, 2019.

[xxx] AirMedCare Network. 2019. (last accessed August 22, 2019)

[xxxi] Carl O'Donnell. 2017. "Exclusive: Buyout Firm KKR in Lead to Acquire Envision's Ambulance Unit – Sources," Reuters , July 14. (last accessed July 19, 2019)

[xxxii] PitchBook. 2019. Air Methods Company Profile dated August 25, 2019.

[xxxiii] Bob Herman. 2017. "Air Methods Bought Out for $2.5 Billion," Axios , March 14. ; Peter Eavis. 2015. "Air Ambulances Offer a Lifeline and Then a Sky-High Bill," New York Times , May5. (last accessed July 28, 2019)

[xxxiv] United States Government Accountability Office. 2019.

[xxxv] Ga Bai, Arjun Chanmugam, Valerie Y. Suslow, and Gerard F. Anderson. 2019. "Air Ambulances with Sky-High Charges," Health Affairs , July: 38(7):1195-1200. (last accessed August 19, 2019)

[xxxvi] Tara Bannow. 2019. "Hospitals' Solution to Surprise Out-Of-Network Bills: Make Physicians Go In-Network." Modern Healthcare. January 12. (last accessed August 13, 2019)

[xxxvii] Tara Bannow. 2019.

[xxxviii] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. Figures 10-11.

[xxxix] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. Figures 12.

[xl] Envision's website states that it is committed to negotiating contracts for 'in-network status whenever possible.' (last accessed August 20, 2019)

[Sep 04, 2019] The NY Times has an article today detailing hospitals suing patients, garnishing wages, and placing liens on property for people with "access" by way of health insurance.

Notable quotes:
"... There is shortage of doctors and nurses(?) but a surfeit of administrators and executives and managers, as it was said in The Godfather, "dipping their beaks." ..."
Sep 04, 2019 |

Jason Boxman , September 3, 2019 at 3:00 pm

Also, on "access", the NY Times has an article today detailing hospitals suing patients, garnishing wages, and placing liens on property for people with "access" by way of health insurance.

What we really need in this country is clearly _more_ access, yes?

What we should be doing is nationalizing all providers. Period. Then we can vastly reduce the number of useless healthcare executives that feed upon American citizens.

Synoia , September 3, 2019 at 3:56 pm

Need a couple of well funded lawsuits, with discovery, to illustrate the lack of disclosures amd mythical charges in Hospital billing.

John , September 3, 2019 at 4:10 pm

There is shortage of doctors and nurses(?) but a surfeit of administrators and executives and managers, as it was said in The Godfather, "dipping their beaks."

Lambert Strether Post author , September 3, 2019 at 4:44 pm

Access to Debt Collectors™ -- a winning program for liberal Democrats!

pretzelattack , September 3, 2019 at 7:33 pm

for some starving seniors, access to food would be nice. hey, maybe there's a market for food insurance, cause adding a layer of predators helps efficiency.

[Sep 01, 2019] Measles epidemic parents reluctant to vaccinate their children need to hear of the horrors of forgotten diseases

Notable quotes:
"... Read more: Measles: should vaccinations be compulsory? ..."
Sep 01, 2019 |

There’s been a surge in measles cases across Europe, putting people’s lives at risk according to new findings from the World Health Organization .

The official figures show that approximately 90,000 cases have been reported for the first half of 2019. This is already more than the number of cases recorded for the whole of 2018 (84,462).

This has in part been put down to disinformation about the MMR (measles, mumps and rubella) vaccine on social media putting parents off vaccinating their children.

Recent outbreaks of measles, which is much more infectious than mumps and rubella, have been widely reported . But what is less well known is that there have been a few babies born with congenital rubella syndrome in the UK in the past few years . This is an illness resulting from an infection of the rubella virus during pregnancy.

Rubella babies

People under the age of 50 are unlikely to have heard about “Rubella babies”, but in the 1940s, the Australian paediatric ophthalmologist, Norman Gregg, made the connection between women being infected with German measles (rubella) during pregnancy and their children being born deaf and blind and sometimes with other disabilities.

Many babies infected with the virus while in the womb do not survive, but in the 1960s in the UK about 300 children each year were born with “congenital rubella syndrome” and needed care. By 1970, a safe effective Rubella vaccine was available and the UK began vaccinating school girls . A screening programme, which involved testing blood samples from women of childbearing age to see whether they had previous immunity to the virus, also began. Those who did not did not have protection were offered the vaccine.

Rubella is a viral illness that causes a mild fever and a skin rash. OneSideProFoto/Shutterstock

Read more: Measles: should vaccinations be compulsory?

Although women starting in particular jobs – such as health care and teaching – were screened, most of the tests were done on pregnant women as part of their 12 week check. In 1988, the Rubella vaccine become the R in the MMR and the strategy changed to vaccinating all pre-school children .

The idea was that if all young children were protected, then these infections would eventually not be circulating at all. During 2016 and 2017, routine screening for Rubella antibodies during pregnancy was phased out across the UK. It was considered not cost-effective, since Rubella infection during pregnancy was extremely rare and most people in the UK of child bearing age should have received MMR as children. But the recent outbreaks of measles across the world have illustrated the problems with MMR uptake .

Misinformation and memory

Why are people reluctant to have screening tests and vaccinations to prevent diseases? While some of the reasons may include loss of trust in “experts” and people in authority, I wonder if it is also partly because the stories of such diseases have been long forgotten.

When Eva Peron, the First Lady of Argentina, died from cervical cancer at the age of 33 in 1952 , for example, early diagnosis was not possible – and chemotherapy treatment was in its infancy. So for women who developed this disease, a distressing illness and painful death were more or less inevitable.

The design of a laboratory method for detecting early changes in the appearance of cells in the cervical region – the “Pap smear” – eventually made regular mass screening possible. Since the introduction of the scheme into the UK in 1988, it has prevented thousands of premature deaths in women each year .

‘Vaccinating the poor of New York City against smallpox in 1872’. In 1863, mass production of smallpox vaccine was developed, allowing for broad immunisation of North American and European populations. Everett Historical/Shutterstock

The discovery that most but, crucially, not all cases of cervical cancer are attributable to Human Papillomavirus (HPV) infection led to the development of the HPV vaccine which is now given routinely to teenage girls – and in some countries boys as well. Evidence from the UK programme, which began in 2009, suggests the vaccine is very effective and this should help to further reduce the number of women with cervical cancer among the under 30s.

Yet despite all that’s known about cervical cancer and the importance of going for a regular smear test, many women still appear to be reluctant to go. It’s estimated that about three million women across England have not had a smear test for at least three-and-a-half years.

In the 20th-century, there were major advances in disease prevention, which improved both life expectancy and quality of life. But it seems these health and societal developments are now being overlooked. Indeed, giving people information and instructions is no longer working. So perhaps it’s time to appeal to people’s hearts by telling the stories of these diseases – and how they have affected real people.

Gruesome photos on cigarette packages , for example, massively help to reduce tobacco use, so maybe something similar now needs to happen in terms of vaccinations to tackle the latest epidemic and anti-vaxxer campaigns around the world.

[Aug 30, 2019] Angry Bear Purdue Offers Up $10 12 Billion to Settle All Lawsuits MedPage Update by run75441

Aug 27, 2019 |

Just revealed:

The opioid/OxyContin maker Purdue and members of the billionaire Sackler family owning the company have offered to settle thousands of lawsuits against the company for $10 to $12 billion. according to people briefed on the offer. More than 2,000 states, cities, and counties across America are pursuing the OxyContin maker over the large bills for cleaning up the opioid crisis -- and are deciding whether to accept the offer by Friday. The Financial Times is reporting on this offer from the Sacklers and Purdue.

On August 26, Purdue paid $270 million to Oklahoma and Teva Pharmaceuticals paid $75 million also to Oklahoma.

From the Financial Times: "Purdue said it believes a 'constructive global resolution is the best way forward' and is working with state attorneys-general and other plaintiffs to achieve it. While Purdue Pharma is prepared to defend itself vigorously in the opioid litigation, the company has made clear that it sees little good coming from years of wasteful litigation and appeals".

For all the harm done to this nation due to purposeful deceit and lies on the use of opioids claiming it was not addictive, someone needs to go to prison from the Sackler family.

Purdue Exposed

Medpage Today, Kristina Fiore, August 28,2019

I suspect with the new information being available, Purdue finally threw in the towel and offered a settlement. I also suspect this will impact other companies decisions to appeal as J & J is doing.

STAT News Wins Legal Fight Over Purdue Documents

A trove of documents detailing Purdue Pharma's role in the opioid epidemic will be made public, STAT News reported, as the Kentucky Supreme Court denied the company's request to review lower courts' decisions to release them.

STAT waged a 3.5-year legal battle to make those records public. While some remain under seal, the outlet posted a sought-after video deposition of Richard Sackler. It had obtained a transcript of that deposition in February, which gained further attention when comedian John Oliver hired famous actors including Bryan Cranston and Michael Keaton to re-enact it.

The documents promise new information on how Purdue promoted its oxycodone product OxyContin and what, exactly, its executives knew about its risk of addiction. Among those documents are depositions of other Purdue executives; physician testimony; emails and memos about marketing strategies; internal reports on clinical trials; and communications about earlier legal cases.

All of the documents were part of Kentucky's lawsuit against Purdue over its alleged illegal marketing of OxyContin. That suit was settled in 2015, with Purdue shelling out $24 million.

Purdue may soon be paying a far higher bill, with media including NBC News reporting that the company has pitched a $10 to $12-billion settlement in the consolidated cases set to go to trial before a federal judge in Ohio in October.

This does not bode well for Purdue, its settlement, or threat of years of litigation. The smoking gun was always there and pieces of it can be found in previous posts of mine. Relating the US Senate Joint Committee numbers to when Oxycontin was introduced after 1995 and the incremental increase in deaths from opioids, the use of a part of the Porter and Jink letter to the NEJM which said opioids were not addictive " minus the part where it said when used in a hospital setting ," the abuse of the Porter and Jink letter in the number of citations , the millions spent in lobbying state legislatures to block new laws, etc.

John Oliver uses Keaton and Cranston to portray Richard Sackler in this 20 minute Clip. It is worth watching. " the launch (Oxycontin) would be followed by a blizzard of prescriptions that will bury the competition. The blizzard will be so deep, dense, and white,."

  1. wooley , August 28, 2019 10:19 am

    Run .I am a 30 year veteran of being a sales person and at times, a sales executive in the networking industry. What these stories reveal is a sustained effort by this company and others to sell as many pills as possible without any controls or brakes on what any responsible sales executive would notice the second his point of sale report came in showing massive amounts of sales to certain individuals or areas. There is no way I can accept that this was not under the control of both sales and marketing at this company. They made bundles of money for years on sales of these highly addictive drugs. They ignored sales to abusers of prescriptions that likely formed the basis for the addiction of millions in order to make quotas and gain bonus money. This stinks to high heaven. Some blame doctors rightly so but do not let them off the hook. A point of sale report shows exactly where all these pills are being sold and Perdue sales management decided not to give a damn.

  1. mike shupp , August 28, 2019 3:03 pm

    These people at Purdue Pharma and Teva are never going to go to prison or even face individual financial penalties -- after all, they are upper class capitalists!

    My suggestion: (1) Reflect that courts have decided that "Corporations are individuals!" And decide to punish the guilty individuals -- seize the corporations. The governments of the UK and USA ought to act to take over all assets of Purdue and Teva -- including all pharmacological products they own or have rights in. Nationalize them. Pay not one cent in compensation to stock holders. Stop paying all employees, and terminate any payments to pension funds. Cease all outgoing payments to suppliers and terminate all leases and real estate transactions.

    Then either operate the seized firms as a government operation, transfer all assets to the National Institute of Health for research purposes, or sell the real property on the open market to the highest bidder, with the purchase money being diverted to compensation of individuals unwittingly addicted to opioids. No one else should benefit from the continued existence of the guilty firms.

    (2) Alternately, state governments should feel encouraged to press for as much compensation as possible from the firms AND THEIR EXECUTIVES until all forced into complete bankruptcy.

    (3) Whichever alternative occurs, economic "experts" should recount this case and its resolution in the first chapter of any ECON 101 textbook they write, or describe the details in the first week or so of freshman/sophomore economic courses. Beginning economics students need to be made really clear about what "the Free Market" actually entails in the modern world. instead of swallowing Ayn Rand-ish fantasies.

    Sigh! To think I used to call myself a libertarian.

[Aug 29, 2019] Opiod epidemic is a a neoliberal Epidemics

Notable quotes:
"... My judgement includes findings of fact and conclusions of law that the state met its burden that the defendants Janssen and Johnson & Johnson's misleading marketing and promotion of opioids created a nuisance as defined by 50 O.S. Sec. 1 , including a finding that those actions compromised the health and safety of thousands of Oklahomans. ..."
"... Specifically, defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma ..."
"... "As I just stated, the opioid crisis has ravaged the state of Oklahoma. It must be abated immediately. For this reason, I am entering an abatement plan that consists of costs totaling $572,102,028 to immediately remediate the nuisance," Balkman said. "This is the amount of costs that I am constrained to order Janssen and Johnson & Johnson to pay based on the particulars of a nuisance claim and the evidence that was presented at trial. ..."
"... Gorsky also assured Johnson & Johnson's business partners the stimulants it plans to produce will be every bit as addictive as opioids and accompanied by an equally widespread misinformation campaign. ..."
Aug 29, 2019 |

Everything went according to neoliberal dogma: Greed is good

As reported:

"I've opted not to read the entire 42-page judgment," Balkman told a packed courtroom in Norman shortly before announcing the numbers in his verdict. "The opioid crisis is an eminent and menace to Oklahomans.

My judgement includes findings of fact and conclusions of law that the state met its burden that the defendants Janssen and Johnson & Johnson's misleading marketing and promotion of opioids created a nuisance as defined by 50 O.S. Sec. 1 , including a finding that those actions compromised the health and safety of thousands of Oklahomans.

Specifically, defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma."

Balkman said the opioid crisis is a "temporary public nuisance that can be abated."

"As I just stated, the opioid crisis has ravaged the state of Oklahoma. It must be abated immediately. For this reason, I am entering an abatement plan that consists of costs totaling $572,102,028 to immediately remediate the nuisance," Balkman said. "This is the amount of costs that I am constrained to order Janssen and Johnson & Johnson to pay based on the particulars of a nuisance claim and the evidence that was presented at trial.

"Whether additional programs and fundings are needed over an extended period of time, those are determinations to be made by our legislators and policy makers. In this moment and based on this record, this is what the court can and will do to abate the nuisance."

Balkman noted that he still has jurisdiction over the case , and that he almost certainly will be asked to make additional rulings.

"So it impossible for me to make any further statements about the trial or my ruling other than what I have said today," Balkman said.

Note that a judge, not a jury set the amount of damages to be awarded. A jury would almost certainly have awarded a higher payout by J & J (although that hypothetical amount may then have been reduced after appeal).

The amount J & J must now pay the state of Oklahoma is significantly greater than the $270 million Purdue Pharma, the manufacturer of OxyContin owned by the Sackler family, and the $85 million Teva Pharmaceuticals, separately agreed previously to settle each's respective Oklahoma claims. \

Additionally, Purdue and Teva also avoided incurring the costs of contesting a trial.

John Zelnicker , August 28, 2019 at 12:25 pm

Jerri-Lynn – Thank you for keeping us updated on the progress of these lawsuits. The pharmaceutical drug dealers need to be held accountable for the damage they have caused. The claim that OxyContin was not addictive, or less so than other opioids, was laughable to anyone who had some experience with them.

There have been three prosecutions locally of doctors who were giving out opioids like candy, even letting nurses write the scrips so the "patients" could be moved through the process more quickly.

I was a patient of one of those doctors (back problems, including surgery) for a while a couple of years before he was prosecuted, lost his license, and had to do some time in prison (IIRC). He seemed to follow most of the rules (and wrote all scrips himself), but was easily persuaded to increase a patient's dosage. Fortunately, I stopped taking opioids before things got hot.

Adam1 , August 28, 2019 at 12:39 pm

Unless it comes with several decades of jail time and confiscation of all private property obtained with ill begot gains (that's what we'd hand a major heroin dealer) then it's not a reasonable settlement.

J&J the company didn't do anything. It's just a legal, non-person thing. The criminals are the people running it and they need to be the ones held liable.

Don't get me wrong. J&J as a company needs to help fix this mess, but we can't let the real criminals slither into the night and drift off on their yachts drinking champagne bought with money taken from ruined families and communities.

PKMKII , August 28, 2019 at 12:43 pm

For context, J&J's net income for 2018 was $15.29 billion. So this particular verdict represents 3.74% of J&J's annual net income.

Annieb , August 28, 2019 at 1:37 pm

To get the full extent of Purdue's criminality, read "American Overdose." The author is Chris McGreal While reading it, I thought that this opioid epidemic began and developed in a similar fashion to the subprime mortgage fiasco with the same type of warnings, collusions and criminal fraud. Huge profits for the corporate criminals. And , tragically, the resulting human consequences, financial ruin in the one case and death in the other.

notabanktoadie , August 28, 2019 at 4:16 pm

In a healthy society, i.e. one with economic justice*, the demand for drugs would be small since there would be little need to escape reality per:

Give strong drink to him who is perishing,
And wine to him whose life is bitter.
Let him drink and forget his poverty
And remember his trouble no more.

Open your mouth for the mute,
For the rights of all the unfortunate.
Open your mouth, judge righteously,
And defend the rights of the afflicted and needy.
Proverbs 31:6-9 [bold added]

*Which certainly would not include government privileges for private credit creation, i.e. for the banks and the rich, the most so-called credit worthy of what is then, in essence, the PUBLIC'S credit but for private profit.

DonCoyote , August 28, 2019 at 4:35 pm

Johnson & Johnson Pledges To Push Uppers For Couple Decades To Even Things Out (The Onion)

Gorsky also assured Johnson & Johnson's business partners the stimulants it plans to produce will be every bit as addictive as opioids and accompanied by an equally widespread misinformation campaign.

I think they forgot to mention that that's where $544 million of the $572 million settlement will go–back to J&J to produce, market, and distribute the uppers.

[Aug 25, 2019] Pruning the tree when spring starts

Aug 25, 2019 |

run75441 | August 25, 2019 8:00 pm

Healthcare Hot Topics End of month July and Pfizer is spinning off Upjohn to generic drug/device company Mylan NV. Pfizer bought 57% of the unnamed (mid – 2020) new company. This move comes under Pfizer CEO Albert Bourla who took over the reins from Ian Read in January, 2019. Bourla has been with Pfizer for 25 years. Before becoming the CEO, Bourla was the Chief Operating Officer (COO) overseeing the company's commercial strategy, manufacturing, and global product development functions.

CEO Bourla has been making strategic moves following what he has called a "pruning the tree when spring starts and Pfizer is in the spring of high growth" strategy. What caught my eye is this one comment in the Wall Street Journal about remaking Pfizer into a company focused on patent-protected prescription medicines with the potential for significant sales growth from a more diversified but slower-growing player. To me, this translate into a; "hey the Mylan EpiPen strategy worked, lets do the same with other products" strategy.

To date, he has overseen a restructuring at the company and made smaller deals to boost Pfizer's pipeline of cancer and other drugs under development. Still not the biggest deal which would make Pfizer a giant. He has been guiding the combining of a division selling Advil, vitamins, bathroom found meds with GlaxoSmithKline PLC's own consumer-health business to be spun off in a joint venture. Nothing earth-shattering there.

CEO Bourla focus for Pfizer on higher profit, exclusive, prescription drugs while moving the rest of its lower profit operations into other ventures. Off-patent drugs such as Lipitor and Viagra having lower profit margins would be targeted for joint ventures and Pfizer would still retain sizeable amounts of cash flow from these drugs to fund R&D. Pfizer is shifting the declining brands to Upjohn. The intent is to consolidate this business with Upjohn and merge Upjohn with the EpiPen company Mylan and rename the two.

The new Pittsburgh – based unnamed company is expected to be among the world's largest sellers of generic and off-patent medicines with more than $19 billion in yearly sales. Pfizer Shareholders will own 57% of the new company and Mylan shareholders would the rest. Pfizer would be paid $12 billion raised from new debt acquired from the joint venture. Upjohn would return to the US from its corporate base in Shanghai, a reversal of its earlier inversion.

To me, this is a strategic move along the lines of Pfizer selling off the marketing of EpiPen to Mylan and keeping the manufacturing of it. Pfizer owned Meridian Medical Technologies manufactured EpiPen for Mylan and it will now be a part of the sale to Mylan. EpiPen was a huge success story for Mylan. A quadrant strategy of milking of a cash cow to fund new ventures.

Including EpiPen, " Mylan's operating profit for its Specialty segment grew from about 35% in 2012 to roughly 60% in the second quarter of 2016." Most of this can be traced back to the change in design of the EpiPen (cap) , exclusivity of it due to design changes which was covered by patents, and the rejection of Teva's generic by the FDA due to a difference in application.

Add to this strategy story, Eli Lilly's Alex Azar's success profiteering off of the decades old diabetes drug Humalog and one can begin is imagine what the new "unnamed" company's role will be under CEO Albert Bourla's direction . . . more of the same.

In its analysis, World Health Organization determined the expenditure of one dollar in R&D being covered by $14.50 profit for cancer pharmaceuticals or more than enough to recoup expenditures for R&D and provide a healthy return for investors. The generics Upjohn will acquire have more than paid back the costs of R&D and are more than likely to be in a decline in producing profits. The question then becomes how to enhance the return on these generics.

Mylan changed Pfizer's EpiPen design to achieve patented exclusivity. Teva could not duplicate it as a generic because patients could not use the Mylan instructions in applying the Teva generic. According to FDA'a rules, the Teva product could not be cast as a generic for the Mylan EpiPen in the marketplace as it could "not" be used in the same manner..

EIi Lilly's Humalog, same formulation as what was made decades ago. The list price for one vial of Humalog has nearly tripled over the last decade. No new and improved or patent changes. Lilly appears to be taking increased profits from the price changes and passing on a larger slice to Pharmaceutical Benefit Managers to gain preference by healthcare insurance plans represented by the PBMs.

The same at the other diabetes med manufacturers Sanofi and Novo. Sanofi , a diabetes drug manufacturer and competitor to Eli Lilly gave insurers and pharmacy benefit managers rebates totaling more than half of its gross sales in the U.S. last year, resulting in net price declines across its portfolio despite list price hikes taken on dozens of its prescription products.

What is occurring is "shadow pricing" increases where one company raises pricing and the others follow.

A lawsuit filed in 2017 alleged three companies ( Eli Lilly , Novo Nordisk, and Sanofi) intentionally raised the list prices on their drugs to gain favorable treatment from pharmacy benefit managers, who work with health insurers and drug makers and help decide how a drug will be covered on a list of approved drugs. Insurance companies do not pay manufacturer list pricing. The PBMs negotiate a rebate to the insurance companies from which they take a portion of it for themselves. The insured gets the net price after Rebates are paid to insurance company minus the PBM bonus for negotiated price.

It is in this circus of net profits after rebates and bonuses, I believe the Upjohn/Mylan "nameless" new company battle will be fought to increase Pfizer's profit. This is not like the EpiPen medical device where a change in design of the pen can be made and a new patent secured. Some drugs may be changed which would result in a new patent. I suspect much of Upjohn/Mylan product profit improvement will be fought by getting preference from Pharmacy Benefit Managers.

CEO Albert Bourla will be watching the new company to see how successful they are in creating preference with PBMs and the resulting profit. Why are our drugs so Costly? Watch the YouTube Presentation to Understand why Drugs are so Expensive to You.

[Aug 08, 2019] Free Market Drugs Are a Really Big Deal

Aug 08, 2019 |

anne , August 03, 2019 at 07:39 AM

August 2, 2019

Big Pharma Current Affairs Dean Baker United States
Why Aren't the Democrats Talking About Ending Patent-Financed Drug Research?

Direct Public Funding: The Alternative to Patent Monopolies.
It would be nice to see Democrats propose plans that would stop the government from making drugs expensive in the first place.

Many of the leading Democratic candidates, especially Bernie Sanders and Elizabeth Warren, have been putting forward bold progressive plans in a wide variety of areas. Sanders and Warren have both supported a quick transition to a universal Medicare program, with no premiums, co-pays, or deductibles. Several candidates have supported a Green New Deal, which in some versions would guarantee every worker in the country a decent paying job.

Such policies are really big deals. They would both have a huge impact on people's lives and also pose serious problems of implementation. The willingness of Democrats to think big in other areas makes their determination to think small on prescription drugs surprising. Replacing government-granted patent monopoly financing of research is both a huge deal and one that can be implemented gradually without threatening massive disruptions in a transition process.

Free Market Drugs Are a Really Big Deal

First, it is necessary to realize that having drugs available at free market prices, without patent monopolies or other forms of exclusivity, would have an enormous impact on the economy and the health care system. On the first point, we will spend more than $460 billion on prescription drugs in 2019. Without patent protection, these drugs would almost certainly sell for less than $80 billion, implying a savings of more than $380 billion. (I go through this calculation here .)

To put this $380 billion figure in context, it is more than five times the annual food stamp budget. It is more than twice the size of the Trump tax cut. If we project out the savings over the course of a decade, they would come to more than $5 trillion. That is more than three times the amount that is projected to be needed to cover the cost of full forgiveness for outstanding student loan debt. This is more than $30,000 per household. In short, there is huge money at stake by any measure.

On the first point, we will spend more than $460 billion on prescription drugs in 2019. Without patent protection, these drugs would almost certainly sell for less than $80 billion, implying a savings of more than $380 billion.

Of course this goes well beyond a dollar and cents calculation. Millions of people facing debilitating conditions or potentially fatal diseases struggle to come up with the money needed to pay for their drugs. This often requires patients and/or their families to battle with insurance companies. The need to raise money for drugs is also now a major use of GoFundMe pages.

If the research was paid in advance, so drugs could be sold as generics, it would not be a struggle to pay for even the newest and most innovative drugs. The price of generics is often less than 1.0 percent of the cost of high-priced drugs in the United States. For example, when the Hepatitis C drug Sovaldi was selling for $50,000 in the United States, a high-quality generic version was available in India for just over $300 for a 12-week course of treatment.

There would be comparable stories for breakthrough drugs and treatments in other areas, many of which now sell for more than $100,000 a year in the United States. The most expensive now cost more than $1 million. Without government-granted patent monopolies, the prices would almost certainly be less than 1.0 percent as high, and possibly closer to 0.1 percent of the current U.S. price.

The basic story is drugs are cheap. It is rare that the manufacturing and distribution process involves major costs. Prices are a problem because of government-granted monopolies.

The patent problem goes beyond prescription drugs. It applies to medical equipment and medical tests as well. An MRI or other scan would just be a couple of hundred dollars if it was a question of covering the wear and tear on the equipment and the pay for a skilled technician to conduct the scan and a doctor to read and assess the findings. It is patent monopolies that make these scans expensive. The savings from ending reliance on patent monopolies in these other areas would probably add $100 to $150 billion annually to the total, another 1.5-2.0 multiples of the annual food stamp budget.

National Public Radio recently did a piece about a woman who had a surprise bill of $94,000 for neuromonitoring services during a surgery on her spine. The reason this process could be billed for $94,000, as opposed to perhaps one-twentieth of this amount, is that the process is patented. If the neuromonitoring system had been developed with public funds, there would be no huge bill with which to surprise patients.

In short, the main reason that so many aspects of medical care are tremendously expensive is that we give companies patent monopolies. Since they are selling items that are essential for people's health or their life, these monopolies allow them to charge outlandish prices. This is the same story as if firefighters set prices based on what it is worth to have family members rescued from burning houses. Needless to say, we would all be willing to pay lots of money in such situations, especially if we could get a third party (e.g., our insurance company or the government) to foot the bill.

Direct Public Funding: The Alternative to Patent Monopolies

The pharmaceutical industry and its supporters in Congress try to pretend that we couldn't possibly develop new drugs without the incentive of patent monopolies. For some reason we are supposed to believe that, even though in all sorts of jobs people work for money, they can only develop drugs with the prospect of getting a patent. I suppose you have to be on the pharmaceutical industry's payroll to understand this logic.

The industry's argument gets even more bizarre when we consider that it is the biggest advocate of increased funding for the National Institutes of Health (NIH). NIH and other agencies get more than $40 billion a year to do biomedical research. This money is primarily spent on basic research.

Somehow we are supposed to believe that this money is well spent, but if the government were to spend more to replace the industry's patent-supported research and clinical testing, it would be the same thing as throwing the money in the toilet. The industry's argument is especially bizarre since many important drugs have actually been developed with government funding. In addition, the NIH has supported thousands of clinical trials.

One interesting comparison is the $2.6 billion that the industry claims it costs it to develop a single drug through patent monopoly financing, with the dozens of drugs and treatments that have been developed by the Drugs for Neglected Diseases Initiative with a cumulative 15-year budget that is less than half of this amount. While there are differences that make the two efforts not strictly comparable, the comparison shows why it is difficult to take seriously the pharmaceutical industry's claims that we have the best possible system for financing research.

There is a good argument for not having all research done directly by the government, but there is no reason that it could not be contracted out to private companies who would operate under long-term contracts. The condition of getting a contract would be that all findings are posted on the internet as soon as practical and that all patentable inventions would be placed in the public domain. (As a practical matter, it would probably be desirable to "copyleft" the patents. This is discussed in somewhat more detail in chapter 5 of Rigged.)

The incentives for a company operating on a long-term contract would be to try to make a case for having a contract renewed and expanded. This would mean doing as much as possible to improve public health in the areas for which they have contracted research. This includes not just developing useful drugs, but also scientific breakthroughs that could lead others to develop useful drugs or other treatments.

Under this public funding system, they would have incentive to publicize their findings as widely as possible..

In this way, the incentives are directly at odds with the patent system. Under the patent system, companies have incentive to keep their findings secret (apart from having to disclose information to get the patent) in order to be best positioned to be able to profit from them. Under this public funding system, they would have incentive to publicize their findings as widely as possible so that they could get credit if they eventually lead to the development of a product or process with important public health benefits.

Another huge advantage of this system is that it would take away the corruption that is endemic to the system of patent-supported drug research. Patent monopolies give drug companies an enormous incentive to push their drugs as widely as possible, even when they may not be the most effective drug or have harmful side effects. Purdue Pharma would not have been pushing OxyContin so vigorously if it were selling at generic prices. While the opioid epidemic is an extreme case, drug companies exaggerate the benefits of their drugs and conceal negative side effects all the time.

Going from Patent Monopolies to Free Market Drugs

There is one other important aspect to the switch away from patent monopoly-supported research to direct public funding; it can be done piecemeal. There is no reason to deny companies the opportunity to go ahead and do research with the expectation that they will recover the costs with their patent monopolies. They just would have to worry that they will be competing with a new drug that is every bit as good, or possibly even better, selling at generic prices.

We don't even have to try to displace patent-supported research all at once. There is no reason the government can't add $4 or $5 billion to its annual spending on NIH to support the development and testing of drugs in specific areas, such as cancer or heart disease. This can allow us both to see how the effectiveness of direct funding compares to patent-supported research and also to uncover whatever problems exist with this mechanism.

Given this simple story, it is difficult to see why none of the more progressive Democratic presidential candidates have taken up the cause of ending patent-monopoly financing of prescription drug research. This failure is especially peculiar, since both Sanders and Warren (along with Senators Booker, Gillibrand, and Klobuchar) were sponsors of a bill that would provide some public funding for research that would lead to new drugs being introduced as generics.

It's great to see the candidates proposing plans that would bring down the cost of prescription drugs. It would be even better to see them propose plans that would stop the government from making them expensive in the first place.

ilsm -> anne... , August 03, 2019 at 08:40 AM
why, democrats are not talking about ending the perpetual wars.... their base in not us.

[Aug 06, 2019] Marianne Williamson suggests that the antidepressants are hugely and recklessly overused.

Notable quotes:
"... Ms. Williamson has criticized the widespread use of antidepressants ; suggested they were to blame for some celebrities' suicides ; characterized treatment guidelines for postpartum depression as a way for pharmaceutical companies to make more money ; and called the distinction between ordinary sadness and clinical depression "artificial." ..."
"... My problem is not with antidepressants per se, which clearly have and do help many people. My problem is only with their overprescription, and the practices of pharmaceutical companies when drugs are marketed in predatory ways." ..."
"... I have met hundreds of people going through hell trying to get off antidepressants that should never have been prescribed to them. I've worked with people going through normal human crises since 1983. And I have seen what has been, in many cases, the devastating effects of overprescription. ..."
Aug 06, 2019 |

In books, interviews and posts on social media, Ms. Williamson has criticized the widespread use of antidepressants ; suggested they were to blame for some celebrities' suicides ; characterized treatment guidelines for postpartum depression as a way for pharmaceutical companies to make more money ; and called the distinction between ordinary sadness and clinical depression "artificial."

How widely antidepressants should be prescribed, and under what circumstances, is a real debate among psychiatrists. But Ms. Williamson has tended to make broad arguments, suggesting that the drugs are hugely and recklessly overused. Mental health experts say comments like these can increase stigma and make people less likely to seek treatment, even if that is not the intention.

... ... ...

"I have no judgment -- nor do I believe I have ever expressed any -- of anyone taking antidepressants," she added in a text message after the interview. "I'm happy for anyone who is finding the help they need for any ailment whatsoever. My problem is not with antidepressants per se, which clearly have and do help many people. My problem is only with their overprescription, and the practices of pharmaceutical companies when drugs are marketed in predatory ways."

... ... ...

She also says she has twice received diagnoses of clinical depression, and writes:

However deep my suffering, I didn't want to be anesthetized as I went through it. Like an expectant mother who wants to give birth naturally, rejecting drugs during labor because she wants to experience "natural childbirth," I wanted to be fully available to the depths of my pain. Why? Because I knew it had something to teach me. I knew that somehow, in some way, my suffering would lead to a blazing new dawn in my life -- but only if I was willing to endure the deep, dark night preceding it.

... ... ...

I have met hundreds of people going through hell trying to get off antidepressants that should never have been prescribed to them. I've worked with people going through normal human crises since 1983. And I have seen what has been, in many cases, the devastating effects of overprescription.

That's not to say that some people do not have serious -- and by the way, I have certainly had experiences where I have said, "I think you should go see a psychiatrist." I can tell you the difference.

One is, "I'm crying because my boyfriend left," and one is someone who can't even look up. I understand the difference, and when someone is showing certain symptoms, I'm the first to say, "I think you should go see a psychiatrist."

[Aug 01, 2019] Private Equity: The Perps Behind Destructive Hospital Surprise Billing

Aug 01, 2019 |

Posted on August 1, 2019 by Yves Smith I have to confess to having missed how private equity is a central bad actor in the "surprise billing" scam that is being targeted by Federal and state legislation. This abuse takes place when hospital patients, even when using a hospital that is in their insurer's network, are hit with charges for "out of network" services that are billed at inflated rack rates. Even patients who have done everything they can to avoid being snared, like insisting their hospital use only in-network doctors for a surgery and even getting their identities in advance to assure compliance, get caught. The hospital is in charge of scheduling and can and will swap in out-of-network practitioners at the last minute.

Private equity maven and co-director of the Center for Economic and Policy Research Eileen Appelbaum explained in an editorial in The Hill in May how private equity firms have bought specialist physicians' practices to exploit the opportunity to hit vulnerable patients with egregious charges:

Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms .

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to .

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

As an example, Appelbaum cites the work of Yale economists who examined what happened when hospitals outsourced their emergency room staffing to the two biggest players, EmCare, which has been traded among several private equity firms and is now owned by KKR and TeamHealth, held by Blackstone:

.after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.

The study also described how TeamHealth extorted insurers by threatening them with high out-of-network charges for "must have" services:

in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.

We'd wondered why California legislation to combat surprise billing got yanked so quickly, with the opponents not even bothering to offer excuses . The official story was that hospitals objected, but the speed of the climbdown looks to have much more to do with the political clout of private equity donors.

The Financial Times yesterday made explicit how proposed Federal legislation would hit KKR's EmCare and other private equity health care predators :

A push on Capitol Hill to stop US patients from being caught unaware by medical bills is weighing on the debt of KKR-backed Envision Healthcare, the target of one of the biggest leveraged buyouts last year

Investors are concerned that a new so-called "surprise billing" law could crimp revenues at companies such as Envision, which employs emergency-room doctors and anaesthetists through its subsidiary EmCare .

"It is like a ransom negotiation: 'I'll hit your enrollees with giant bills unless you pay me enough money not to do that'," said Loren Adler, associate director at USC-Brookings Schaeffer Initiative for Health Policy.

The debt that has gone wobbly. Recall that so-called credit funds, also managed by private equity firms, are big buyers of the leveraged loans that private equity firms use to finance their acquisitions. And public pension funds like CalPERS invest in these credit funds:

Envision's $5.4bn loan due in 2025, sold in September when investor demand for leveraged loans was very strong, slid from almost 97 cents on the dollar at the start of May to just 87.8 cents on the dollar on Thursday, as more detail surrounding possible legislation has been released.

Leveraged loans for Blackstone's TeamHealth and private-equity-owned air ambulance companies Air Methods and Air Medical have also taken hits.

The normally cool-headed, pro-business Financial Times readers were almost without exception appalled: "..highway robbers .smacks of fraud sheer criminality .ambushing patients .criminals." Welcome to health care, USA style.

Sadly, the article says that while both parties are eager to be seen to be Doing Something about health care costs, neither wants to give the other side a win, making new Federal legislation unlikely in the current session. But exposing private equity as the hidden hand behind this extortion may lead to more inquisitiveness about the degree to which private equity finding and exploiting economic choke-points has contributed to the suffering.

Tom Stone , August 1, 2019 at 6:50 am

The Hospital that both my Primary Care Physician and my Cardiologist are affiliated with has outsourced their Emergency Room.
If you show up needing care RIGHT NOW, your choice is to scrawl an assent on their little I Pad or die.
I landed there twice this year, and the bills are just starting to show up from the first trip.
If I live long enough to bother I'll fight them on the basis that I signed under duress and if that doesn't fly there's Bankruptcy.

Christopher Herbert , August 1, 2019 at 7:26 am

One of the peculiarities of our wildly inefficient medical care industry is that there are so many 'pens' in the ink bottle that overhead costs eat up money that should be used to improve services.

I describe our medical care system as a '100 silos' system. The jumble is enormously expensive. We generously fund this industry, but we do not get anywhere near the benefit.

Mark , August 1, 2019 at 7:53 am

"Consent is for in-network services only and excludes out-of-network services"

Elisabeth Rosenthal in "An American Sickness" suggested that one add this statement to the consent forms one is required to sign as a strategy to inoculate oneself against this practice. I've not had an opportunity to try it and was wondering if anyone has done it and if there was a reaction or objection from the provider.

Also Mark , August 1, 2019 at 11:06 am

For years, I have written words to the effect of "All charges not covered by insurance will be paid at a rate to be negotiated" on health care providers' financial responsibility forms, and initialed the addition. I've never had a doctor's office or hospital challenge it. I think most don't even notice that I've done it.

I've also never had to invoke it, so I don't know how effective it is, but thinking I am at least somewhat protected from surprise bills gives me some comfort in the face of our crazy health care system.

By the way, I routinely cite "An American Sickness" when making the point to people that it's not just the pharmaceutical companies and the insurance companies. It's pretty much every part of the health care industry.

Elspeth , August 1, 2019 at 11:45 am

I do it, every time, you just need to smile when you do so they know you still love them.

Jim A. , August 1, 2019 at 8:31 am

Which brings up what I was thinking about during last night's debate: Insurance companies are only SOME of the profit seeking pigs chowing down at the healthcare trough. Even if we eliminate them in a "medicare for all" plan the rest of of them will gladly eat their share. It would take something more like a VA for all plan with hospitals run by the government to deal with some of the others.

jfleni , August 1, 2019 at 8:41 am

What a surprise the medical OFFAL will #### you to the max when you need help;
YAHOO, up ###, Medicare for ALL,RIGHT NOW!!! SCREAM it to your congress-critter!

Mark , August 1, 2019 at 8:41 am

Who 'yanked' the California legislation?

Their names would help voters to hold them accountable.

TBone , August 1, 2019 at 9:19 am

If this does not change in 2020 I'm moving to a civilized nation like Canada even if I have to walk there. Grrrrrr this is SO WRONG. How do retirees apply to move to Canada? Are they letting us in anymore???

TBone , August 1, 2019 at 9:23 am

Oh new plan necessay, I can't pay that much for 5 years.

TBone , August 1, 2019 at 9:26 am

I'm just gonna avoid the medical system forever and die at home of natural causes or go to New Jersey for assisted suicide if necessary. Thanks USA medical crapification you filthy greedy (family blog)

ambrit , August 1, 2019 at 10:14 am

Don't just crawl off to an obscure corner and expire passively. Take some Medical Industry execs with you when you go. /s?

hemeantwell , August 1, 2019 at 10:49 am

/s? = ?

ambrit , August 1, 2019 at 11:03 am

/s = ending sarcasm tag. So that s/ = beginning sarcasm tag.
/s? = ending sarcasm tag indicates real sarcasm?

Chris , August 1, 2019 at 10:03 am

Class action lawsuit against south western Ohio hospital's and surgeon for balance billing:–law/lawsuit-filed-against-premier-health-surgeon/DSEkWli4T4RR7VKoE8VJfP/amp.html

softie , August 1, 2019 at 10:09 am

In 2012, a neighbor's kid stayed three days in the hospital when his motorcycle got him into an accident. The bill is almost half million dollars.

flora , August 1, 2019 at 10:27 am

Thanks very much for this post. This is a PE medical extortion racket, imo.

Off The Street , August 1, 2019 at 10:40 am

My plumber showed me a type of client rights form that he is required to present during various repairs. That form is essentially a mitigant against being extorted, given the potential for such behaviors during exigent circumstances. Drip, drip, drip turns into flooding, or no hot water turns into challenges with dishes and washing clothes. Now envision your elderly relative in that situation.

An unscrupulous repairman could make some extra money by exploiting such circumstances, turning a seemingly innocent service call into triple golden time toward that new Mercedes. Disclosure: phrase inspiration from an old Frasier episode.

ambrit , August 1, 2019 at 11:11 am

I once worked for such a dishonest plumbing service company, for a very short time. I was fired after I refused to do unnecessary work at a customers house so as to jack up the bill. That outfit, and another I briefly worked for later were both cases where investor syndicates had 'bought' the companies, with predictable implementation of maladaptive behaviours.
"For the love of money is the root of all evil." 1 Timothy 6:10

Susan the other` , August 1, 2019 at 11:37 am

Thank you. This is astonishing info. Because medicine is changing quicker than lumbering, conniving private equity can kludge together new extortion rackets. It almost feels like PE is running in place. And everybody is on to them thanks to info like this. Just FYI, our new hospital that claims it is a non-profit health care corporation has just built a new wing for "specialty clinics" housed on site. And of course it has been their billing practice from day one to inform you that you might receive additional bills from any of these physicians. So far this seems to be under control. We've had 4 same-day surgeries there and no big surprises. But there is obviously a reason to establish this loophole. The takeover of emergency rooms by KKR/EM Care and Blackstone Team Health is pure extortion. Extortion lurking in the wings. I hope PE rots in hell sooner than later.

Anon , August 1, 2019 at 12:14 pm

The intro to the post could have been an instant replay of my hospital experience. Reading the many comments about medical billing shenanigans is somewhat "comforting" in that my experience wasn't singular. However, it is important that more people recognize the hospital billing scam and that some doctors have never memorized the Hippocratic Oath. If today's modern medicine saves you, the medical billing will likely "kill" you.

sleepy , August 1, 2019 at 12:19 pm

Speak of the devil. Right now, I'm sitting in a clinic waiting room while my wife has minor surgery for a basal cell carcinoma. She went to a medicare advantage plan awhile back due to the high premiums of her medicare supplemental plan. She was assured everything was in her network. We'll see, I guess.

[Jul 30, 2019] One side effect of Prozac is that the patient becomes "disconnected" -- loses his capacity for empathy by Sally Morris

So do antidepressants create an army of artificial psychopaths, especially in high positions of power?
Jul 30, 2019 |

Originally from: Marianne Williamson is Right America is Addicted to Antidepressant Drugs

... ... ...

One of the first major drug "breakthroughs" was Prozac. Prozac acts like a stimulant but masks depression. Two books should be mentioned here: Listening to Prozac by Peter D. Kramer, wherein the author promotes the wonder drug, suggesting it as the answer to some of the great problems of human psychology; and Talking Back to Prozac by Peter and Ginger Breggins, in which the authors analyze and raise questions about the drug's approval process, questioning what it might mean in terms of public safety. Examining their case histories and side effects, Prozac seems fatally flawed, undeserving of the public's confidence.

For the last several years or so, many of our mass murder episodes have been perpetrated by those who have been on psychotropic drugs, either antidepressants or drugs for attention deficit disorder. (Even drugs to quit smoking can be harmful, such as Chantix, which is 18 times more likely to be linked with violence compared to other drugs, according to Time .) These drugs are being prescribed, urged on parents by frustrated schoolteachers, with the acquiescence of those who stand to make profits, all without regard to the side effects that can emerge in shocking ways.

One side effect, or intended effect, is that the patient becomes "disconnected" -- loses his capacity for empathy. This, apparently, is one way to numb him against psychological pain and depression. But it doesn't bode well for the long term, whether in personal relationships, parenting, working, or socializing. And worst of all, it opens the door to a possible eruption of public violence in the future. This possibility alone should give us pause in accepting drugs as a solution to our pain.

... ... ...

Sally Morris is a Minnesota writer and musician. Her articles have appeared in the Dakota Beacon, the New Americana, and the American Thinker, as well as her local newspaper, where she wrote a series of interviews with World War II veterans. When not writing, she is performing on the Celtic harp.

[Jul 23, 2019] Some thoughts about Mueller testimony

Notable quotes:
"... Imagine you are a horny 15 year old boy and you have been promised sex with an incredible Hollywood talent. Driven by surging hormones your anticipation and excitement are off the scale. You are taken to the place where the tryst will happen. And you open the door. Waiting of you is Barney Fife. ..."
Jul 23, 2019 |

Imagine you are a horny 15 year old boy and you have been promised sex with an incredible Hollywood talent. Driven by surging hormones your anticipation and excitement are off the scale. You are taken to the place where the tryst will happen. And you open the door. Waiting of you is Barney Fife.

That sort of sums up what is likely to happen tomorrow when Robert Mueller testifies before the House Judiciary and the House Intelligence committees. I have shut off almost all cable news. I cannot stomach the relentless hype about tomorrow's supposed "big day."

Blackberet , 23 July 2019 at 02:18 PM

Hmmm, given how the legacy media has managed to completely misinterpret what Mueller's Report actually says, imagine what a field day they will have interpreting "nothing" to mean something. Now, I wonder what that something might be...?

[Jul 23, 2019] The Downside of Having a Sweet Tooth - The New York Times

Jul 23, 2019 |

recent reports have found that regular consumption of sugary drinks heightens the risk not only of tooth decay, obesity, fatty liver disease and Type 2 diabetes, but also of heart disease and premature death, even in people free of other risk factors.

You may have encountered contrary findings -- reports that seemed to exonerate sugar consumption as a health hazard. Companies that produce sugar-laden foods and drinks would like you to believe that ailments linked to sugars result from excess calories, not sugars themselves. Don't believe them; most reports holding sugar blameless are from sources tied directly or indirectly to financial support from the industries that depend on caloric sweeteners.

... ... ...

The latest findings underscore the advice from experts on diet, health and weight control to avoiding drinking one's calories, except perhaps for a glass of wine with dinner. And, it turns out, serious health risks are not limited to liquid sources of sugar; the sugars found in processed solid foods, including many that do not even taste sweet, can be hazards, too, if overconsumed.

... ... ...

To clarify the effects of our high-sugar diet, I consulted an expert, Kimber L. Stanhope, a researcher in nutritional biology at the University of California, Davis, whose work is free of industry support and funded primarily by the National Institutes of Health. In a comprehensive 34-page review of research published in Critical Reviews in Clinical Laboratory Sciences in 2016 , she linked consumption of added sugar to metabolic disease -- cardiovascular disease, Type 2 diabetes and nonalcoholic fatty liver disease -- as well as high blood levels of uric acid, a risk factor for kidney stones and gout.

In studies done in her lab among young adults consuming their normal diets, the risk for developing heart disease and kidney stones rose in direct proportion to the amount of high-fructose corn syrup they consumed.

"Fructose and glucose are not metabolized the same way in the human body," which can account for the adverse effects of fructose, Dr. Stanhope said. Glucose is metabolized in cells throughout the body and used for energy. Fructose is metabolized in the liver, resulting in fat production and raising the risk of heart and fatty-liver disease. In addition, she explained, "fructose doesn't stimulate the satiety-promoting substance leptin," prompting some people to overconsume it, especially in soft drinks containing high-fructose corn syrup, and other tempting foods as well.

... ... ...

Meanwhile, her advice to consumers is to cut their sugar intake by two-thirds: Reduce the current 15 percent average daily calories from added sugars to 5 percent, as recommended by the American Heart Association, easiest if done gradually. Learn to routinely peruse packaged food labels for the kinds and amounts of sugars they contain.

Jane Brody is the Personal Health columnist, a position she has held since 1976. She has written more than a dozen books including the best sellers "Jane Brody's Nutrition Book" and "Jane Brody's Good Food Book."

[Jun 30, 2019] Life Expectancy Falters In The UK Slow Death But Fast Profits For The Agrochemical Sector by Colin Todhunter

Notable quotes:
"... "We are being poisoned by weedkiller and other pesticides in our food and weedkiller sprayed indiscriminately on our communities. The media remain silent." ..."
"... Mason notes that the agency repeatedly failed to hold Monsanto accountable for its role in the pollution (a role that Monsanto denied from the outset) and consistently downplayed the dangers of the chemicals themselves. ..."
"... In a report prepared for the agency and the local authority in 2005 but never made public, the sites contain at least 67 toxic chemicals. Seven PCBs have been identified, along with vinyl chlorides and naphthalene. The unlined quarry is still leaking, the report says: ..."
"... Apart from these events in Wales, Mason outlines the overall toxic nature of Monsanto in the UK. For instance, she discusses the shockingly high levels of weedkiller in packaged cereals. Samples of four oat-based breakfast cereals marketed for children in the UK were recently sent to the Health Research Institute, Fairfield, Iowa, an accredited laboratory for glyphosate testing. Dr Fagan, the director of the centre, says of the results: ..."
"... "These results are consistently concerning. The levels consumed in a single daily helping of any one of these cereals, even the one with the lowest level of contamination, is sufficient to put the person's glyphosate levels above the levels that cause fatty liver disease in rats (and likely in people). ..."
"... Another study notes neurotransmitter changes in rat brain regions following glyphosate exposure. The highlights from that study indicate that glyphosate oral exposure caused neurotoxicity in rats; that brain regions were susceptible to changes in CNS monoamine levels; that glyphosate reduced 5-HT, DA, NE levels in a brain regional- and dose-related manner; and that glyphosate altered the serotoninergic, dopaminergic and noradrenergic systems. ..."
"... "Our children are growing up exposed to a toxic cocktail of weedkillers, insecticides, and fungicides. It's on their food and in their water, and it's even doused over their parks and playgrounds. Many governments insist that our standards of protection from these pesticides are strong enough. But as a scientist and a lawyer who specialises in chemicals and their potential impact on people's fundamental rights, I beg to differ. Last month it was revealed that in recommending that glyphosate – the world's most widely-used pesticide – was safe, the EU's food safety watchdog copied and pasted pages of a report directly from Monsanto , the pesticie's manufacturer. Revelations like these are simply shocking. ..."
"... At that stage, PCBs, DDT, chlordane, lindane, aldrin, dieldrin, endrin, toxaphene, heptachlor, dioxin, atrazine+ and dacthal were shown to be EDCs. Many of these residues are found in humans in the UK. ..."
"... Of course, the chickens are now coming home to roost for Bayer, which bought Monsanto. Mason refers to attorneys revealing Monsanto's criminal strategy for keeping Roundup on the market and the company being hit with $2 billion verdict in the third 'Roundup trial'. ..."
"... Attorney Brent Wisner has argued that Monsanto spent decades suppressing science linking its glyphosate-based weedkiller product to cancer by ghost-writing academic articles and feeding the EPA "bad science". He asked the jury to 'punish' Monsanto with a $1 billion punitive damages award. On Monday 13 May, the jury found Monsanto liable for failure to warn claims, design defect claims, negligence claims and negligent failure to warn claims. ..."
"... "Perhaps more ominously for Bayer, Monsanto also faces cascading scientific evidence linking glyphosate to a constellation of other injuries that have become prevalent since its introduction, including obesity, depression, Alzheimer's, ADHD, autism, multiple sclerosis, Parkinson's, kidney disease, and inflammatory bowel disease, brain, breast and prostate cancer, miscarriage, birth defects and declining sperm counts. Strong science suggests glyphosate is the culprit in the exploding epidemics of celiac disease, colitis, gluten sensitivities, diabetes and non-alcoholic liver cancer which, for the first time, is attacking children as young as 10. ..."
"... Rosemary Mason shows that the health of the UK populations already lags behind other countries in Western Europe. She links this to the increasing amounts of agrochemicals being applied to crops. If the UK does a post-Brexit deal with the US, we can only expect a gutting of environmental standards at the behest of the US and its corporations and much worse to follow for the environment and public health. ..."
Jun 30, 2019 |

Authored by Colin Todhunter via,

A special report in the Observer newspaper in the UK on 23 June 2019 asked the question: Why is life expectancy faltering? The piece noted that for the first time in 100 years, Britons are dying earlier. The UK now has the worst health trends in Western Europe.

Aside from the figures for the elderly and the deprived, there has also been a worrying change in infant mortality rates. Since 2014, the rate has increased every year: the figure for 2017 is significantly higher than the one in 2014. To explain this increase in infant mortality, certain experts blame it on 'austerity', fewer midwives, an overstrained ambulance service, general deterioration of hospitals, greater poverty among pregnant women and cuts that mean there are fewer health visitors for patients in need.

While all these explanations may be valid, according to environmental campaigner Dr Rosemary Mason, there is something the mainstream narrative is avoiding. She says:

"We are being poisoned by weedkiller and other pesticides in our food and weedkiller sprayed indiscriminately on our communities. The media remain silent."

The poisoning of the UK public by the agrochemical industry is the focus of her new report – Why is life expectancy faltering: The British Government has worked with Monsanto and Bayer since 1949 .

What follows are edited highlights of the text in which she cites many official sources and reports as well as numerous peer-reviewed studies in support of her arguments. Readers can access the report here .

Toxic history of Monsanto in the UK

Mason begins by offering a brief history of Monsanto in the UK. In 1949, that company set up a chemical factory in Newport, Wales, where it manufactured PCBs until 1977 and a number of other dangerous chemicals. Monsanto was eventually found to be dumping toxic waste in the River Severn, public waterways and sewerage. It then paid a contractor which illegally dumped thousands of tons of cancer-causing chemicals, including PCBs, dioxins and Agent Orange derivatives, at two quarries in Wales – Brofiscin (80,000 tonnes) and Maendy (42,000 tonnes) – between 1965 and 1972.

Monsanto stopped making PCBs in Anniston US in 1971 because of various scandals. However, the British government agreed to ramp up production at the Monsanto plant in Newport. In 2003, when toxic effluent from the quarry started leaking into people's streams in Grosfaen, just outside Cardiff, the Environment Agency – a government agency concerned with flooding and pollution – was hired to clean up the site in 2005.

Mason notes that the agency repeatedly failed to hold Monsanto accountable for its role in the pollution (a role that Monsanto denied from the outset) and consistently downplayed the dangers of the chemicals themselves.

In a report prepared for the agency and the local authority in 2005 but never made public, the sites contain at least 67 toxic chemicals. Seven PCBs have been identified, along with vinyl chlorides and naphthalene. The unlined quarry is still leaking, the report says:

"Pollution of water has been occurring since the 1970s, the waste and groundwater has been shown to contain significant quantities of poisonous, noxious and polluting material, pollution of waters will continue to occur."

The duplicity continues

Apart from these events in Wales, Mason outlines the overall toxic nature of Monsanto in the UK. For instance, she discusses the shockingly high levels of weedkiller in packaged cereals. Samples of four oat-based breakfast cereals marketed for children in the UK were recently sent to the Health Research Institute, Fairfield, Iowa, an accredited laboratory for glyphosate testing. Dr Fagan, the director of the centre, says of the results:

"These results are consistently concerning. The levels consumed in a single daily helping of any one of these cereals, even the one with the lowest level of contamination, is sufficient to put the person's glyphosate levels above the levels that cause fatty liver disease in rats (and likely in people). "

According to Mason, the European Food Safety Authority and the European Commission colluded with the European Glyphosate Task Force and allowed it to write the re-assessment of glyphosate. She lists key peer-reviewed studies, which the Glyphosate Task Force conveniently omitted from its review, from South America where GM crops are grown. In fact, many papers come from Latin American countries where they grow almost exclusively GM Roundup Ready Crops.

Mason cites one study that references many papers from around the world that confirm glyphosate-based herbicides like Monsanto's Roundup are damaging to the development of the foetal brain and that repeated exposure is toxic to the adult human brain and may result in alterations in locomotor activity, feelings of anxiety and memory impairment.

Another study notes neurotransmitter changes in rat brain regions following glyphosate exposure. The highlights from that study indicate that glyphosate oral exposure caused neurotoxicity in rats; that brain regions were susceptible to changes in CNS monoamine levels; that glyphosate reduced 5-HT, DA, NE levels in a brain regional- and dose-related manner; and that glyphosate altered the serotoninergic, dopaminergic and noradrenergic systems.

Little wonder, Mason concludes, that we see various degenerative conditions on the rise. She turns her attention to children, the most vulnerable section of the population, and refers to the UN expert on toxicity Baskut Tuncak. He wrote a scathing piece in the Guardian on 06/11/2017 on the effects of agrotoxins on children's health:

"Our children are growing up exposed to a toxic cocktail of weedkillers, insecticides, and fungicides. It's on their food and in their water, and it's even doused over their parks and playgrounds. Many governments insist that our standards of protection from these pesticides are strong enough. But as a scientist and a lawyer who specialises in chemicals and their potential impact on people's fundamental rights, I beg to differ. Last month it was revealed that in recommending that glyphosate – the world's most widely-used pesticide – was safe, the EU's food safety watchdog copied and pasted pages of a report directly from Monsanto , the pesticie's manufacturer. Revelations like these are simply shocking.

" Exposure in pregnancy and childhood is linked to birth defects, diabetes, and cancer. Because a child's developing body is more sensitive to exposure than adults and takes in more of everything – relative to their size, children eat, breathe, and drink much more than adults – they are particularly vulnerable to these toxic chemicals. Increasing evidence shows that even at "low" doses of childhood exposure, irreversible health impacts can result.

" In light of revelations such as the copy-and-paste scandal, a careful re-examination of the performance of states is required. The overwhelming reliance of regulators on industry-funded studies, the exclusion of independent science from assessments, and the confidentiality of studies relied upon by authorities must change."

Warnings ignored

It is a travesty that Theo Colborn's crucial research in the early 1990s into the chemicals that were changing humans and the environment was ignored. Mason discusses his work into endocrine disrupting chemicals (EDCs), man-made chemicals that became widespread in the environment after WW II.

In a book published in 1996, 'The Pesticide Conspiracy', Colborn, Dumanoski and Peters revealed the full horror of what was happening to the world as a result of contamination with EDCs.

At the time, there was emerging scientific research about how a wide range of man-made chemicals disrupt delicate hormone systems in humans. These systems play a critical role in processes ranging from human sexual development to behaviour, intelligence, and the functioning of the immune system.

At that stage, PCBs, DDT, chlordane, lindane, aldrin, dieldrin, endrin, toxaphene, heptachlor, dioxin, atrazine+ and dacthal were shown to be EDCs. Many of these residues are found in humans in the UK.

Colborn illustrated the problem by constructing a diagram of the journey of a PCB molecule from a factory in Alabama into a polar bear in the Arctic. He stated:

"The concentration of persistent chemicals can be magnified millions of times as they travel to the ends of the earth... Many chemicals that threaten the next generation have found their way into our bodies. There is no safe, uncontaminated place. "

Mason describes how EDCs interfere with delicate hormone systems in sexual development. Glyphosate is an endocrine disruptor and a nervous system disruptor. She ponders whether Colborn foresaw the outcome whereby humans become confused about their gender or sex.

She then discusses the widespread contamination of people in the UK. One study conducted at the start of this century concluded that every person tested was contaminated by a cocktail of known highly toxic chemicals that were banned from use in the UK during the 1970s and which continue to pose unknown health risks: the highest number of chemicals found in any one person was 49 – nearly two thirds (63 per cent) of the chemicals looked for.

Corruption exposed

Mason discusses corporate duplicity and the institutionalised corruption that allows agrochemicals to get to the commercial market. She notes the catastrophic impacts of these substances on health and the NHS and the environment.

Of course, the chickens are now coming home to roost for Bayer, which bought Monsanto. Mason refers to attorneys revealing Monsanto's criminal strategy for keeping Roundup on the market and the company being hit with $2 billion verdict in the third 'Roundup trial'.

Attorney Brent Wisner has argued that Monsanto spent decades suppressing science linking its glyphosate-based weedkiller product to cancer by ghost-writing academic articles and feeding the EPA "bad science". He asked the jury to 'punish' Monsanto with a $1 billion punitive damages award. On Monday 13 May, the jury found Monsanto liable for failure to warn claims, design defect claims, negligence claims and negligent failure to warn claims.

Robert F Kennedy Jr., another attorney fighting Bayer in the courts, says Roundup causes a constellation of other injuries apart from Non-Hodgkin's Lymphoma:

"Perhaps more ominously for Bayer, Monsanto also faces cascading scientific evidence linking glyphosate to a constellation of other injuries that have become prevalent since its introduction, including obesity, depression, Alzheimer's, ADHD, autism, multiple sclerosis, Parkinson's, kidney disease, and inflammatory bowel disease, brain, breast and prostate cancer, miscarriage, birth defects and declining sperm counts. Strong science suggests glyphosate is the culprit in the exploding epidemics of celiac disease, colitis, gluten sensitivities, diabetes and non-alcoholic liver cancer which, for the first time, is attacking children as young as 10.

In finishing, Mason notes the disturbing willingness of the current UK government to usher in GM Roundup Ready crops in the wake of Brexit. Where pesticides are concerned, the EU's precautionary principle could be ditched in favour of a US-style risk-based approach, allowing faster authorisation.

Rosemary Mason shows that the health of the UK populations already lags behind other countries in Western Europe. She links this to the increasing amounts of agrochemicals being applied to crops. If the UK does a post-Brexit deal with the US, we can only expect a gutting of environmental standards at the behest of the US and its corporations and much worse to follow for the environment and public health.

Sinophile , 54 minutes ago link

If a chemical is deadly to a plant, it could not possibly be deadly to anything else. Right?

******* idiots. This comment section is full of ******* idiots.

Check out this clip from the CBC:

Anyway, it ain't just glyphosates. We live in a toxic world today. They sicken us with their chemicals and then reap profit from their pharmaceuticals used to treat our symptoms. Never a cure. No profit in that. Keep us alive and sick and using their pharmaceuticals to mask the symptoms. Die before you can collect SS. That's the plan.

Stormblessed , 1 hour ago link

Noise. People live for roughly 80 years, big deal. That's way longer than in the '50's or earlier.

kbohip , 4 hours ago link

Blaming glyphosate, which has been used for decades for a decline in life expectancy that began only in 2014 doesn't make any sense. If glyphosate really was that cancer causing, it would have led to a decline decades ago I would think. That being said, I have a bunch of hard to kill weeds in my backyard (not in the lawn) that I want to get rid of. One in particular is a real problem as it's not actually a weed but a plant that was put in before I moved here. It can't easily be pulled or even touched by my weed eater as it has a poison inside that burns the skin and lungs. I intend to use glyphosate if I have to, but I'm open to other suggestions from people here that would also get the job done.

AGuy , 3 hours ago link

" If glyphosate really was that cancer causing, it would have led to a decline decades ago I would think. "

Monasanto was just stupid to claim Glyphosate didn't have an pontential toxic properties. It would have just been wise to put on the label: "Do not ingest or inhale, May contain toxic and carcinogens. where protective gloves and clothing when handling. Do not apply near streams, ponds or other sources of fresh water."

If someone gets sick, they are not liable or have limited liability.

" I intend to use glyphosate if I have to, but I'm open to other suggestions from people here that would also get the job done. "

Just use protective clothing & gloves when handling what ever herbicide you use. Avoid spraying in a way that you might inhale or get exposure. FWIW: I have a hogweed growing on my property. Way too dangerous to touch of get near. I am going try using Glyphosate to kill it, if that does do it, I try another herbicide.

Hogweed is very dangerous: Like poison ivy only about 1000 times worse. Even lightly touching it can cause very nasty skin lesions. Herbicide is the only safe way to get rid of it.

Ignore This , 4 hours ago link

Weedkiller is killing people because ... we said so!
But what if it isn't weedkiller? What if it is plastic bottles or food preservative or over the counter pain remedies? We would never know because ZH says it's weed killer. It could be a combination of many things. Since this is affecting people in their late 80's, anything that generation was exposed to in the past 80 years could be to blame including during World War II. I realize that rational thought is frowned upon on ZH but have a little skepticism. This is the Internet after all.

delmar Jackson , 5 hours ago link

Roundup was sold to farmers for 30 years as a safe way to help harvest their crops and reduce the growth of mold which can be much more toxic then many man made chemicals. I am less worried about monsanto than I am drug overdoses that are killing over 70,000 people a year. Instead of bombing Iran we need to bomb China and mexico for all of the death causing drugs they have imported into our country. Over a quarter of a million people are dead from drugs like heroin and fentanyl in the last 4 years.

AGuy , 3 hours ago link

" Roundup was sold to farmers for 30 years as a safe way to help harvest their crops and reduce the growth of mold which can be much more toxic then many man made chemicals. "

Nope, its used as a herbicide to kill everything before they plant a crop so the weeds don't compete with the crop.

" I am less worried about monsanto than I am drug overdoses that are killing over 70,000 people a year. "

ODs aren't as terrible as food\water contamination. Any sane person will not abuse opioids. Look at this way: there are 70K less people living on welfare or some other gov't subsidy. However Food\Water contamination is a big deal since its difficult for even the sanest people to avoid it. OD is usually a life choice, Food\Water contamination is not.

Xena fobe , 7 hours ago link

Same in the US. Lowered standard of living. Mass migrations and elite 1% burdening the poor and middle class.

[Jun 30, 2019] Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

Jun 30, 2019 |

OCnStiggs , 2 hours ago link

Couldn't be the British National Healthcare System now could it? You know, the one where elderly patients are wheeled on gurneys to wait out the weekend in darkened corridors with minimal attention. If they survive the weekend, they get a new room and more care. Most die a lonely death because the system has deemed them past their productive age. Only the best from Big Gubmint.

Just sayin'.

silent one , 1 hour ago link

One ploy, experienced by my mother 75, blood pressure too high so on meds to lower it, then set date of op 6 weeks in advance, take blood for testing 4 weeks before the op, turn up on day of op wait 2 hours for nurse to come and tell her the results of the blood test 4 weeks earlier indicate her sodium is to low and cancel the op, told to up the sodium and referred back to doctor, told by doctor nurse on holiday for two weeks creating a delay, 3 weeks later for blood test to decide how many salt pills to prescribe, delay for subsequent blood test, week before blood test hospital phone to say it has taken to long for the blood tests so have taken her off the waiting list and referred her back to the doctor to start the process all over again. My mother a little old lady is in a lot of pain, now talking about ending it all. THE ******* CUNTS

Mariposa de Oro , 1 hour ago link

So sorry to hear of this. I hope things get better for her. Also, is there a naturopathic doctor in the area you can take her too?

Umh , 59 minutes ago link

Incompetence has limits that can be exceeded by bureaucratic incompetence. Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

[Jun 27, 2019] Something about neoliberal MSM

Jun 27, 2019 |

Curtis , Jun 26, 2019 6:12:43 PM | 54

michaelj72 #37
I'm the Slime - Frank Zappa

I am gross and perverted
I'm obsessed 'n deranged
I have existed for years
But very little has changed
I'm the tool of the Government
And industry too
For I am destined to rule
And regulate you

I may be vile and pernicious
But you can't look away
I make you think I'm delicious
With the stuff that I say
I'm the best you can get
Have you guessed me yet?
I'm the slime oozin' out
From your TV set

You will obey me while I lead you
And eat the garbage that I feed you
Until the day that we don't need you
Don't go for help . . . no one will heed you
Your mind is totally controlled
It has been stuffed into my mold
And you will do as you are told
Until the rights to you are sold

[Jun 22, 2019] 1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care

Notable quotes:
"... By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News . ..."
"... On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.) ..."
"... The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. ..."
"... Each time ..."
"... "but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays." ..."
"... inpatient stays ..."
Jun 22, 2019 |

1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care naked capitalism

Posted on June 22, 2019 by Lambert Strether Lambert here: But it doesn't matter. People love their health insurance companies! (And do note the role, entirely accidental I am sure, played by body shops outside staffing firms.)

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News .

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

"Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017," the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM's MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were "very worried" about unexpected medical bills.

Surprise bills don't just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn't employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

"It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital.

"By definition, there are these circumstances where they cannot choose their provider, whether it's an emergency or it's [a doctor] who gets brought in and they don't even meet them face-to-face."

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don't apply to most large-employer plans because the federal government regulates them.

"New York and California have very high rates of surprise bills even though they have some of the strongest state statutes," Pollitz said. "These data show why federal legislation would matter."

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente. <img src="" />

Arizona Slim , June 22, 2019 at 7:26 am

Seriously, who are these people who love their health insurance?

Pat , June 22, 2019 at 8:58 am

At this point, I am pretty sure with few exceptions the people who love their insurance are top management and or the companies that negotiate these profiteering contracts with those same insurance companies. Only the bubble beltway hasn't gotten the message. Witness all those people at the Fox Town Hall with Sanders that shocked the moderators when they asked the gotcha question about their employer health insurance.

Amfortas the hippie , June 22, 2019 at 7:55 am

""It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital."

again no menu, no price tags, no team shirts .
it ain't a "market".

(""rational actors with perfect information" lol)

we've got around 10k in debt for the first month or so of our long emergency with cancer the period before medicaid kicked in.
some of it will get paid.
most of it will likely not(something about blood and turnips )

interestingly and apparently largely unknown is that one can get a "debt consolidation loan" for credit card, mortgage, and other "consumer" debt .but not for medical debt.
you must, instead, deal with fifty bill collectors representing many medical outfits you may have never heard of -- -imaging, labs, that guy in a white coat who walked by and looked in the door --
one of the articles of faith with the neoliberal order, is that since transactions are inherently Good, it makes sense to maximise them.
so instead of the floor doctor being employed by the hospital, itself she is employed by an LLC with an anodyne, hard to remember, name.

"It's kind of a built-in problem,"

a global economy of pickpockets.

Monty , June 22, 2019 at 10:08 am

Sounds awful. The last thing you need is extra stress at a time like that. Deepest sympathies. Here's hoping it works out for you all.

NY Geezer , June 22, 2019 at 8:20 am

The problem here is not the health insurer. It is corruption in the provision of medical services by the in network hospital that permits out of network doctor staffing agencies and doctors to perform expected medical services on its premises.

I live in the Capital district area of NY. I discovered recently that almost all the hospitals here have entered into contracts with emergency care staffing corporations for the provision of medical care. In addition, Urgent care facilities staffed by only Physician's Assistants are proliferating here. This area is apparently regarded as a good target for medical profiteers.

Pat , June 22, 2019 at 8:52 am

In a rational society, you know one where the recognizes the captive or powerless entity and provides them the protection they are denied, the hospital/medical group etc would be responsible to make sure all parities working there are in network. And by law all additional out of network charges would be theirs.

Of course in a truly enlightened and rational society we would have single payer and the government would use all its power making sure that society at all levels were healthy and well cared for when they weren't. And massive profits would be on things that were truly discretionary like private jets and yachts not on emergency care.

Bobby Gladd , June 22, 2019 at 9:29 am

In 2015 I came down with sepsis after a prostate biopsy (which turned out positive for cancer). Was admitted to John Muir hospital in Walnut Creek via the ER (I was a Muir system patient at the time). Subsequently got a bill advising that the Emergency Dept at Muir was "out of your Network" (an "independent contractor"). Eye roll.

'Nuther thing I already knew, but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher ) deductibles and co-pays.

ambrit , June 22, 2019 at 9:46 am

Ah. Now that's news I can use. As I mentioned below, I spoke to a claims adjuster yesterday concerning my bus accident. One of the questions she asked was about my eligibility for Medicare. So, the question wasn't just informational in nature. Real money is involved.
Thanks for the enlightenment.

Bobby Gladd , June 22, 2019 at 10:32 am

My late daughter was a Kaiser-Permanente member. She was admitted to a KP hospital several times during her recent Stage IV pancreatic cancer ordeal (she died 15 months ago). Each time , she had to go through the ER for admission. Even Kaiser , who owns their own hospitals, subs out their ERs to "independent contractors," which, of course, raised Danielle's co-pays and "co-insurance." The only route to admission was an 8-12 hr "triage" stint in the ER.

There's hardly any such thing as a through-the-front-door "elective admission" any more.

ambrit , June 22, 2019 at 11:02 am

That's the definition of fraud, right there.
When I was on a jury hearing a "pill mill" case from Biloxi Mississippi, we were told that one definition of a "pill mill" was when the 'patient' was required to go through, and pay for, a full doctors appointment for what was essentially a renewal of a pre-existing prescription. The mandatory "triage" endurance each time a "regular" patient was admitted for an already diagnosed condition fits this definition. Perhaps a resort to the RICO provision would be salutary.
Sorry about your daughter. I hope she 'passed' peacefully.

Bobby Gladd , June 22, 2019 at 4:26 pm

Thanks. Danielle died peacefully (6 weeks into home hospice care), but her illness was anything but.

Talk about "surprise bills," the night at the ER she decided to go into hospice care rather than do another futile admit, they insisted she come home via ambulance (subbed out to the city fire & rescue dept) -- all 1.9 miles to our house. After she died, I kept getting bills for her, one of which was about $2,500 for the ambulance ride ( "Seriously?" ). Needless to say, that did not get paid. Wish in one hand, [bleep] in the other, see which one fills up faster. She died way beyond broke, there was no "estate" to be probated or attached. Not that a host of claimants didn't repeatedly try. They all came to know Bad Bobby, who, while not a lawyer, was way ready for all of them (It wasn't my first rodeo, and I didn't want anyone BS'ing my grandson into assuming any bogus liabilities).

Cal2 , June 22, 2019 at 12:54 pm

Good to know, many of my friends are getting Medicare Part B insurance solicitations from Kaiser. Will inform them to look elsewhere. My condolences to you Sir.

Everyone needs to use things like Yelp and other rating services to make such things known to the curious public.

jake , June 22, 2019 at 4:14 pm

"but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays."

I don't get it. You want ER services to fall under Part B ("out patient"), because it has a relatively small deductible. And once it's satisfied, you're clear for the year.

Part A, for hospital admissions, has a much larger deductible, and it's applied per admission, not per year.

Bobby Gladd , June 22, 2019 at 5:48 pm

Well, legally, because you're not yet admitted "to the floor," it's necessarily an outpatient encounter. People just don't know that generally. You're right about the "deductible." The co-insurance is quite another matter ( apropos of both A and B). Which is why one needs a "Medi-Gap" supp. Humana Medi-gap lost their butts on me last year. In June after Danielle died I had hernia surgery, followed by open heart aortic valve replacement ("SAVR px") in late August. My OoP for the year was nil. Thank you Humana.

In a bit of irony, I'm now Kaiser, "Medicare Advantage." My OoP caps for the year at $6,700. Though, I don't expect anything major, got all my heavy lifting done in 2015 and last year.

Oh , June 22, 2019 at 9:35 am

They prey on the weak and helpless, especially the ones that go for emergency care. This is another example of hospitals not really caring for the well being of the sick. Once they capture a victim, their aim is to suck him dry.

The insurance companies are to blame too because they allow the out of network charges to occur. The insured doesn't know what service or provider is "in network". He makes a good faith attempt to go to "in network" hospitals but then the gougers take over.

ambrit , June 22, 2019 at 9:41 am

The 'attending physician' I saw during my ER sojourn after last month's bus accident was a "Body Shop Droid." The bill I received, which was the one I described earlier, the semi-threatening one, was from an "Emergency Room Physicians Management Company LLC." I have nothing to compare it to, but it came to just over $700 dollars US, for two or three 'look see's' at my battered carcass.
The ambulance "service," a properly neo-liberalized separate commercial entity, (anyone remember when ambulances were a part of the hospital apparat?,) billed me just over $1000 dollars US. I finally reached a claims adjuster for the bus companies insurance company yesterday. One of the questions she asked me, after I had established that I had been 'ambulanced' to the hospital was, how many people were transported in that one ambulance? When I quipped about 'double dipping' on the part of the ambulance "services," she laughed and said, "If you only knew."
I have still not heard from the hospital itself.

Mark , June 22, 2019 at 10:15 am

In Elisabeth Rosenthal's excellent book "An
American Sickness" she recommends adding the following statement to any consent form you sign in the hospital "Consent is limited to in-network services only and excludes out-of-network services". My wife and I carry copies of this in our wallets just in case. Haven't had occasion to try this yet and see their reaction.

Bobby Gladd , June 22, 2019 at 10:21 am

" An American Sickness ," yes, an important read.

Oh , June 22, 2019 at 12:16 pm

Yes, a well written expose.

Cal2 , June 22, 2019 at 1:07 pm

"I read 1,182 emergency room bills this year. Here's what I learned."

The corollary of "Someone has to pay!" is "Someone gets it for free."

What happens locally at San Franciscan General Hospital:

Undocumented person or homeless guy;
1.Get ride to hospital in ambulance.
2. Get free translator, if needed
3. Claim no I.D.
4. Get treatment.
5. Pick up free meds at pharmacy.
6. "No hope of recovery"= "Free"

American citizen with insurance
1. Walk in hospital.
2. Spend half an hour proving I have insurance.
3. Get treatment.
4. Get bill for hundreds of thousands because they "are out of network ."

A state bill is in the works to ban this. However, taxpayers will still provide free care for indigents and now, per a new state law, not only illegals in emergency rooms, but all illegals, until age 26, get full medical inpatient insurance coverage, paid by taxpayers.

Joe Well , June 22, 2019 at 3:47 pm

If you have to link to the National Review to support your opinion, maybe you should rethink your opinion.

Cal2 , June 22, 2019 at 4:28 pm

E pur si muove!

Synoia , June 22, 2019 at 2:00 pm

I'm with Kaiser in CA.

I just send their member services this, based on the wording by Mark above.

"Kaiser Emergency Room Consent is limited to in-network services only and excludes out-of-network services."

I will post responses from Kaiser.

samhill , June 22, 2019 at 3:22 pm

Being first gen Italian I applied for Italian citizenship back before Eurolandia was consummated just in case the rules were changed. Main reason was worries over my on and off health insurance, so just to be safe. Sure enough found myself in my fifties w/o insurance, which is a seriously unwise situation, and hesitently moved to Italy. It's been rough to say the least, the country is deep in the dumps, but the health system is WONDERFUL. Yeh, everyone moans and complains about a long list of valid problems with health care here, but they have no idea the alternative. I tell everyone here to mark my words and protect what they got from the devious, erosive neo-liberal threat.

Preaching to the choir on NC but just in case anyone has doubts the positives; no financial stress to compound health stress, no corporate bureaucracy, state system is quite well streamlined, no copays if you're unemployed or poor, outweighs ALL the negatives.

dk , June 22, 2019 at 4:55 pm

I think the title is a little inaccurate, it's not 1-in-6 patients, it's 1-in-6 visits (or stays). Two visits in a year bring an individual's odds to 1-in-3, etc.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge.

Also, note "at least," aggregation removes detail.

From the study:

Even when patients were admitted to in-network facilities, though, 16% of these stays resulted in at least one out-of-network charge for a professional service.

And out-of-network charges can occur for simple services like a blood test, this recently happened to a friend. She visited a service office listed by her insurer, but the office had contracted with an out-of-network analysis lab, resulting in a non-covered $1100+ charge. Which is a bit amazing in itself, during a recent checkup (my first in 12 years) which was covered by a Medicaid plan, I inquired about the costs for my various tests, to understand affordability; how much would this or that cost if I walked in without any coverage plan? My comprehensive blood test would have cost $183, my echo-cardiogram $118. What about the hormone-level test my friend got? Under $500. All these prices are for cash up front of course, avoiding the 25%+ in interest and finance fees that a payment plan would incur.

GroundZeroAndLovinIt , June 22, 2019 at 5:05 pm

Tangentially, I just saw an anti-Medicare for All ad on TV in my market yesterday (the DC metro area), the first such I have seen. The focus of the ad was that M4A would result in long wait times for procedures; 4 weeks for a cancer consultation, 8 weeks for a kidney replacement consultation, and so on. The ad was so patently misleading it was kind of astonishing: people already wait many many weeks for medical consultations under our gloriously inefficient "excellent" healthcare system–a fact I'm sure most Americans are familiar with. I know of people with cancer diagnoses who have had to wait months to get an appointment with a specialist. So, I'm surprised that's the tack that the lobbyists would take in their "M4A will ruin everything" scary ad. That was the whole focus of the ad: wait times. Seemed like a weak tea argument to me.

flora , June 22, 2019 at 5:16 pm

In the DC metro area?
The healthcare industry spends four times as much on lobbying as the MIC.
That ad is part of the lobbying blitz, imo.

[Jun 05, 2019] Lawmakers Push To Stop Surprise ER Billing

Jun 05, 2019 |

May 30, 2019 by Yves Smith Yves here. This article is a bit fuzzier than I'd like on the details of how the proposed California legislation to bar balanced billing would work, and past failures to halt this practice says that details matter.

However, as I read this piece, the intent is make health insurance work like old-fashioned indemnity plans, at least as far as emergency room coverage is concerned. Indemnity plans were once the norm, and the insured could go to any doctor. No network, no GP gatekeeping.

The sticky part here is the patient is supposed to be on the hook for only what he'd have to pay if he went to an emergency room that was in network. That would seem to give the upper hand to the insurance companies, since the hospital has no recourse to the patient beyond his obligation for an in-network visit. The insurer sends the same reimbursement to the out-of-network hospital as it would to an in-network hospital, and washes its hands of the matter.

One downside for the insurer is that they will now be on the hook for ER bills from any hospital. So they will wind up increasing premiums as a result. But routine care, managing chronic conditions like diabetes, and scheduled surgeries still constitute the substantial majority of what those premiums are intended to cover.

By Ana B. Ibarra, Reporter for California Healthline, based in Sacramento. Previously, she covered health in California's Central Valley for the Merced Sun-Star. She is a 2015 Center for Health Journalism fellow and a Cal Poly Pomona graduate. Originally published at Kaiser Health News

California has some of the nation's strongest protections against surprise medical bills. But many Californians still get slammed with huge out-of-network charges.

State lawmakers are now trying to close gaps in the law with a bill that would limit how much hospitals outside of a patient's insurance network can charge for emergency care.

"We thought the practice of balance billing had been addressed," said state Assemblyman David Chiu (D-San Francisco), author of the bill . "Turns out there are major holes in the law potentially impacting millions of Californians with different types of insurance."

"Balance billing," better known as surprise billing, occurs when a patient receives care from a doctor or hospital -- or another provider -- outside of her insurance plan's network, and then the doctor or hospital bills the patient for the amount insurance didn't cover. These bills can soar into the tens of thousands of dollars .

Chiu's proposal would prohibit out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles. Hospitals are fighting the proposal, calling it a form of rate-setting.

"If we are able to move this forward in California, it could be a model and standard for what happens around the country," Chiu said of his measure, which the state Assembly is expected to consider this week.

Surprise billing is a scourge for patients around the country.

Last year , a Kaiser Family Foundation poll found that two-thirds of Americans are "very worried" or "somewhat worried" about being able to afford a surprise bill for themselves or a family member. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Health policy experts say the problem demands federal action rather than an inconsistent patchwork of state laws. And President Donald Trump has called on Congress to pass legislation this year to put a stop to surprise medical bills.

"In one swipe, the federal government can offer a universal approach in protecting consumers," said Kevin Lucia, a research professor with Georgetown University's Health Policy Institute.

Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups -- health insurers and health providers -- have been unable to agree on a solution.

Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered "comprehensive," according to the Commonwealth Fund . California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada , which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California's protections don't cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn't apply to the millions of residents with health plans regulated by the federal government.

Chiu's bill attempts to close those loopholes by targeting hospitals and their billing practices. With this strategy, a patient's health plan -- and the agency that regulates it -- would not matter, explained Anthony Wright, executive director of Health Access California, a Sacramento-based advocacy group that is sponsoring the legislation.

The proposal "extends protections to a broader set of Californians," Wright said.

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region .

The association believes that would equate to the state setting prices, which could discourage health plans from entering contracts with hospitals, said Jan Emerson-Shea, a spokeswoman for the association.

"We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern," she said.

Chiu said his bill was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital spotlighted by Vox in January.

Unlike most large hospitals, San Francisco General does not contract with private insurers. Vox found that the hospital considered patients with private insurance out-of-network, and was slapping many of them with whopping bills.

Stefania Kappes-Rocha was one of them.

On April 30, 2018, Kappes-Rocha, 23, landed in San Francisco General's emergency room with a fever and intense pain in her lower right back caused by a kidney infection. A student at Hult International Business School at the time, she had a private plan through the college.

"I didn't know it at the time, but that was the problem -- that I did have insurance," Kappes-Rocha said.

She was sent home a day later with ibuprofen. About two months later, she was billed $27,767.70.

"I couldn't move because of the pain," she said. The last thing on her mind was that she'd be on the hook for the entire cost of her hospital visit.

Her insurance eventually agreed to pay about $24,000 of her bill.

"I fought back, I pressured them every week," she said. "But some people don't know they should do that."

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.

Joe Well , May 30, 2019 at 10:21 am

I think it is "balance billing" as in "your insurer pays part and you pay the remaining outstanding balance."

Thank you so much for this article on yet another crime against the 99%!

Cal2 , May 30, 2019 at 11:40 am

There's a reason that this state bill originated in the civic disaster that is San Francisco.

San Francisco General, now named for the billionaire, used to be an excellent public teaching hospital affiliated with the University of California. It has one of the better trauma units in California, thanks to the proximity of nearby gang turf wars and housing projects that keep it replenished with fresh gunshot wounds.

Someone has to pick up the tab for San Francisco being a magnet for the uninsured homeless and undocumented from all over the western hemisphere. All this is very expensive.

The city has a dedicated health plan for the "undocumented."

Billions have been spent on free health care for "homeless" people.

More spending coming:

The word among some locals, third generation Americans, who grew up in the city, even those who have insurance , if they go to the emergency room, is to claim to not be insured, give a false name and social security number for emergency treatment. That idea came from refugees flushing their passport down the toilet on the plane.

Joe Well , May 30, 2019 at 12:50 pm

OK, I actually followed the link to the SF Chronicle you posted to support the claim that in SF, one city, "billions have been spent on free health care for 'homeless' (scare quotes?? why??) people."

In fact, that article does not even use the word "healthcare" and implies the exact opposite of what you claim, stating that 2.2% of a $250 million annual budget dedicating to homelessness issues was spent on "health services" for the homeless. The vast bulk of the budget went to fight evictions and keep housed people from becoming homeless. It does not discuss emergency departments at all.

You're making stuff up, not just little things, but enormous things.

Might I add, IMHO, this kind of thing is typical of conservatives, and dovetails nicely with today's post about conservative ideology dying out.

Cal2 , May 30, 2019 at 1:21 pm

You corrected my pre-coffee error. Thank you.
People that make things up don't post a contradictory URL.

"Billions have been spent on the homeless in San Francisco", is what I meant to say. Healthcare is part of that, which includes ambulance rides, fire department calls. BTW, there's lots of debate about numbers. "Billions includes housing, subsidies etc.

Why "homeless" quotes? There are actual Homeless people who have been kicked out of public housing or who simply cannot afford rents. The majority of the "homeless" in San Francisco are recently arrived who have never had a home here, move from place to place and are mostly just junkies and drug users, who would continue to be, even if given "a home."

I'm a Bernie, Medicare for All, Peace in The Middle East, free transit, tax the wealthy "conservative", glad they are coming around.

Joe Well , May 30, 2019 at 10:10 pm

You should actually read that article you linked to.

Where is your figure for the billions that were supposedly spent on the homeless in San Francisco coming from? As that article makes clear, most of the money is being spent on people who live in apartments in San Francisco, to keep them from becoming homeless. Another huge chunk is spent on people who are homeless and in precarious temporary arrangements rather than on the street. Very little is being spent on the "visible homeless" as the article calls them.

Your general impression that SF is a net economic contributor in any way to American society is absurd. It is sucking wealth out with scam companies like Uber while it is casting out lower income people to every other corner of the state and country.

If SF did take in some homeless people and provide them a few thousand dollars a year of services, that would be a drop in the bucket compared to the damage its citizens have done. But you have not provided one word of evidence that the homeless in SF have primarily come from out of town, much less out of state. Given the Bay Area's efforts to gentrify over the decades, it seems quite likely that they were formerly housed inhabitants of the city.

Cal2 , May 31, 2019 at 8:53 pm

"Your general impression that SF is a net economic contributor in any way to American society is absurd."
You must be confusing me with someone else?
I think San Francisco is a giant black hole of exorbitant social services for "homeless", illegals, and profit sucking billionaires that often pay zero local taxes. i.e. Twitter, in it's special Mid Market Resurrection Zone. All those stock options think of the savings.
Add up the money spent over the last 25 years or so on homeless and preventing homelessness and it's in the billions.
$40,000 per "homeless" person per year. With the passage of Proposition C, to go to $70,000 per year.

Here's article with per year expenditures on homeless:

I grew up in San Francisco and have been involved in local politics for half a century. So where are you from? Where are you getting your numbers? Please share. We can all learn from each other.

KevinD , May 30, 2019 at 11:54 am

As long as the people making the rules are monetarily above worrying about health care costs, the rest of us will continue to get squeezed out of existence. Put some people in charge who cannot afford today's medical costs and you will see them go down. Pretty simple actually ( at least in my head)

Anon , May 30, 2019 at 1:54 pm

I have direct experience with this sort of 'balance billing'. It's not just the hospitals that do it. Doctors are a big part of the problem, too.

My doctor recommended major surgery and so we scheduled a specific time and date with the hospital. My medical insurance required the use of in network doctors. So I explained to the chief nurse (in a long discussion prior to admittance) at the in-network hospital I needed to vet ALL doctors for their network status. Actually put it in writing. (I gave them a list of the known in-network doctors affiliated with the hospital.)

Survived the surgery (as you can tell). But to my surprise a 'balance bill' appeared in the mail. Then another. What?! I don't recognize any of these people (doctors). In California the Legislature has given the State Medical Board authority over hospital operating room procedure. The medical board 'requires' three doctors to be 'present' in the operating room for certain major surgeries; they are selected by the primary surgeon. These other two doctors, whom I was never introduced to (before or after surgery) had sent me the unexpected billing (with no discussion of the medical work they performed– or not) in the mail. Of course, they were not in-network and my insurance initially refused to pay them.

Long story shortened, I was able to convince my insurance provider to pay them in-network fees. The doctors refused it, we went to court, they got nothing (zero, nada, zilch). Written record carried the day.

Hospital care in America is a wild ride. You literally need a personal advocate every minute you are in one.

Joe Well , May 30, 2019 at 10:13 pm

Congratulations on your victory and for fighting the good fight.

I have tried hard to get as much of my healthcare as possible outside the US.

I am confident that many American specialist doctors are decent people, but too many of them are clearly greedy.

wilroncanada , May 31, 2019 at 4:53 pm

Canadian specialist doctors who are REALLY greedy may stay around and join those trying to privatize our system, or they may move to the US where greed is king. We made the mistake back in the 1970s of engaging an obstetrician at a maternity hospital in Vancouver for the birth of our first two children. For our oldest he showed up seconds before the birth, leaving a me and a resident who had not done a birth before. Of course, the nurses knew exactly what to do. His fee from medicare was, I guess, being there to catch. With our second two years later, he knew exactly what might happen–my wife would race through the transition phase of labour and almost immediately into delivery. That did not matter to him, he still arrived within seconds of delivery completion.
Our third was with a GP in a different city. He was a REAL doctor, present and supportive. It didn't matter, though, because the obstetrician had moved to Texas where he could schedule caesareans around his golf game.

baldski , May 30, 2019 at 10:29 pm

I have a Medicare PPO from Humana. The hospital selected by them for emergencies is Northern Nevada. I happened to fall off my porch and hurt my arm. I went to the emergency room and was told I had a fractured elbow. Some time later Humana denied the payment for the attending doctor because he was in the group of emergency physicians that man the emergency room and were not in Humana's network. Catch-22 – The emergency room bill is in network but the doctors are not.

Calling all lawyers: Please answer.

Is this not Agency of Estoppel on Humana's part?

The Emergency Room of Northern Nevada Hospital is writ large by a large neon sign. The doctors there are contracted with Northern Nevada and practice in their facility. I contend that the doctors are agents of the hospital and Humana is denying that agency by not paying the bill. Agency of Estoppel is illegal, I was taught in my limited business law course.

Any lawyer out there please respond.

run75441 , May 31, 2019 at 10:31 pm


What you have just described is pretty common in Texas. These doctors do not have a contract with the hospital and are usually 3rd party. Is your PPO supplemental or are you in an Advantage (BS) Plan? If you are truly in Medicare and using a Supplemental for the 20% of Part B not covered, you are safe.

If you are in an Advantage Plan I would go back to Humana and ask them to negotiate a price. Not an attorney; but, doctors are agents of the hospital whether 3rd party and contracted or employed.

Paul P , June 1, 2019 at 2:23 am

The hospital is in network, they ask for your insurance,
and then supply out of network doctors, who don't contact you to enter into a contract to provide out of network services. i don't see how a contract has been
made with these out of network doctors.

You probably signed an ABN ("I'm responsible for what
insurance does not pay."} So, that is an "I gotcha" in favor of their right to bill you. I've been crossing out their ABNs and writing I will only be responsible for what insurance pays.

run75441 , June 1, 2019 at 9:58 pm


When you go to the ER, you get whoever comes through the door which baldski got. Again what I will say, this is happening with greater frequency and especially in Texas where a hospital contracts the ER doctors out to a 3rd party and does not negotiate the ER rates. It is like having a vendor in your hospital who is contracted to the hospital and charges whatever price. There is a term for this and it is little more than entrapment.

Janie , May 30, 2019 at 2:25 pm

Every one of us should be concerned about this. We are vulnerable, even in our homes. Ambulances take you to the nearest hospital where there is space in Emergency, not necessarily to one in your network. You may be unconscious or incoherent.

Next issue:. Ongoing care. A friend had a pancreatitis attack while on vacation. After ER, he was admitted and told he needed immediate surgery. His insurance company refused to pay for the surgery, saying he could have returned home safely. As you can imagine, the bill was a big one. Insurance never came through, and he settled with the hospital for a large amount.

Joe Well , May 30, 2019 at 10:17 pm

I think the issue with balance billing is not whether the ER is in your network. Here in Massachusetts, for instance, health plans cover every ER visit to every ER on earth. The issue is that some of the doctors provide services which are for whatever reason not considered "emergency" for the purposes of your health plan and if that doctor is out of network, you get charged for the "balance" beyond whatever small amount the plan will pay. Oftentimes the doctors are greedy sharks and pile on the charges which understandably the insurer is unwilling to pay.

The ER admission itself is only a manageable amount, about $500 when I went. It was the fees and medications that added up.

run75441 , May 31, 2019 at 10:33 pm


As you "may" know, they are 3rd party and contracted.

Bob Hertz , May 31, 2019 at 12:54 pm

In Yves's fine piece, a spokesman for hospitals complained that the new legislation was a form of 'rate setting."

Well heck yes. When consumers are helpless and a legitimate contract is impossible, it is accepted that courts and legislatures can regulate the fees.

For that matter, Maryland has had regulated hospital charges for several decades, and I know of no crisis that has occurred nor of a hospital that went broke.

The very idea that every hospital bill for emergencies should involve attorneys and the media is grotesque. Seeiing the hospital as a greedy, grabbing institution that sets fees at $100,000 and accepts $10,000 would be considered idiotic in most nations. In Germany, a bargaining unit for all hospitals meets annually with a bargaining unit for all insurers and they set all the fees. In America, hospitals
"bargain" esssentially by financial terrorism.

run75441 , May 31, 2019 at 10:53 pm


That is Maryland which does regulate pricing.

The other 49 states do not regulate pricing and set market rates. Places like University of Michigan hospital charge more than other generic hospitals, As hospitals consolidate, there is less competition as the most recent Commonwealth Fund funded Health Affairs study determined in their findings. Indeed from 2007 to 2014, hospital-prices for inpatient care grew 42% compared to 18 percent for physician-prices for inpatient hospital care. For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices.

If you go to a hospital with 3rd party doctors, they can balance bill you. We are not in Germany and it varies state by state what can be done.

You being an insurance guy like ME should already know this as you expound about it over at Charles Gaba's site.

[May 30, 2019] Trump: Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing

Notable quotes:
"... May 9 - surprise medical bills will be outlawed ..."
May 30, 2019 |

powerandpeople , May 29, 2019 6:45:22 PM | 8

Regarding a candidate addressing a really important domestic issue in USA, Pres. Trump has drawn the teeth (to an extent) on that one, and put the Democratic party in the position of either supporting the Republican initiative, or throwing sand in the wheels of a measure which will be very popular with the American public:

May 9 - surprise medical bills will be outlawed

"...Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing...we have bipartisan support, which is rather shocking..."

powerandpeople , May 29, 2019 6:49:29 PM | 9

website URL for press release info on ending surprise medical billing and provision for cheap generics

[May 21, 2019] physical activity

May 21, 2019 |

after meals has a profound impact on blood sugar levels for people with type 1 diabetes , preliminary research suggests.

"We were surprised at our findings," says Mayo Clinic endocrinologist Yogish Kudva, MBBS.

People with diabetes who engaged in basic physical activity after eating had blood sugar levels close to those of people without the condition, the study showed. Those who remained sedentary after meals had elevated blood sugar levels.

"You don't have to exercise a lot. Just walking the dog or washing the dishes after a meal, rather than going straight from the table to the TV, helps blood sugar control in people with type 1 diabetes ," Kudva tells WebMD. "Physical activity enhances insulin action, hence lowering blood glucose concentration."

Exercise and Diabetes

About 3 million Americans have type 1 diabetes , which is usually diagnosed in childhood or young adulthood. It's an autoimmune disease in which the body destroys its own ability to make insulin , which is needed to properly regulate blood sugar.

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For the study, the researchers monitored 14 people without diabetes and seven people with type 1 diabetes over a four-day period at the Mayo Clinic in Rochester, Minn.

Participants were given three identical meals each day. After one meal each day, participants laid in bed for six hours. After the other meals, they engaged in physical activity. Overall, participants walked at a moderate pace for an average of 3 to 4 miles a day, "about the same as the average American," Kudva says.

The sugars in one meal a day were labeled with a safe tracing dye so the researchers could measure how much sugar from food went in and how much came out.

The findings were presented here at the annual meeting of the American Diabetes Association.

Checking Blood Sugar Levels

Among people without diabetes, post-meal blood glucose levels increased an average of 50 milligrams per deciliter (mg/dL) if they exercised after eating. That is what we like to see in healthy people," Kudva says. Readings increased by up to 100 mg/dL if they were inactive.


Among people with type 1 diabetes, blood glucose levels rose an average of 80 milligrams per deciliter if they exercised after eating and 150 mg/dL if they were inactive.

Most people without diabetes have blood sugar levels in the 70s, while people with the condition aim for a reading of 70-130 mg/dL. The recommended post-meal blood sugar level for people with diabetes is less than 180 mg/dL.

"If a diabetic patient's blood sugar is 100 or higher before eating, an increase of 150 is pretty significant," Kudva says. Over time, persistently high blood sugar can give rise to a host of complications ranging from blindness to kidney problems, he says.

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James B. Meigs, MD, of Harvard Medical School, tells WebMD that there's been a lot of debate about the right amount of exercise for people with diabetes.

"This confirms that a little exercise is better than none. It's the people who are really sedentary who have poor blood sugar control," he says.

These findings were presented at a medical conference. They should be considered preliminary as they have not yet undergone the "peer review" process, in which outside experts scrutinize the data prior to publication in a medical journal.

WebMD Health News Reviewed by Laura J. Martin, MD on June 27, 2011 Sources SOURCES:

71st Scientific Sessions of American Diabetes Association, San Diego, June 24-28, 2011.

Yogish Kudva, MBBS, department of endocrinology, Mayo Clinic, Rochester, Minn.

James B. Meigs, MD, Harvard Medical School. © 2011 WebMD, LLC. All rights reserved.


[May 21, 2019] Why Type 2 Diabetics Should Exercise after Eating

Notable quotes:
"... First, he eliminated all processed and refined foods from his diet and focused mostly on foods with a low glycemic index of 55 or less ..."
May 21, 2019 |

My friend Paul was diagnosed with type 2 diabetes a few years ago. He was also obese and experienced other common symptoms associated with diabetes, such as blurry vision, fatigue, and an increased thirst and appetite.

Paul decided it was time to change his lifestyle and eating habits -- he understood that type 2 diabetes can eventually lead to kidney disease , nerve disorders, vision loss , hypertension, stroke, and heart disease.

Today, Paul is 30 pounds lighter and has successfully managed to regulate his blood sugar levels.

Key Ingredients for Diabetes Control: Diet and Exercise

Paul credits his success to two simple things:

When Should Diabetics Exercise?

Paul asked me if there was anything else he could do to lower his risk of developing cardiovascular issues associated with type 2 diabetes (such as heart attack or stroke).

I informed Paul of exciting new research published in the Journal of Applied Physiology . Researchers from the University of Missouri-Columbia found that people with type 2 diabetes can more effectively reduce their risk of developing a cardiovascular disease when they exercise after a meal.

The study found that resistance exercise is more effective with lowering blood sugar and fat levels after a meal. The researchers observed 13 type 2 diabetics. One day, the participants would perform resistance exercises before dinner. On another occasion they would exercise for about 45 minutes after dinner. The resistance exercises included abdominal crunches, leg curls, and seated calf raises.

The results? Participants who exercised after dinner saw a reduction in their blood fat and sugar levels, while those who exercised before dinner only saw a reduction in blood sugar levels. All of the participants consumed dinners that had a moderate carbohydrate intake.

Exercise Tips and Tricks for Type 2 Diabetics
  1. Ease into your exercise : While resistance training is best for diabetics, it is best to start slow if you are currently inactive. You can start doing any type of exercise, including walking, yoga, qigong, tai chi, or swimming. Start with 10-minute sessions each day and then move up to 30 minutes daily.
  2. Follow a regular routine : To prevent diabetes complications, like low blood sugar, it is best to exercise at similar times every day.
  3. Strength train a minimum of twice weekly : Once you are comfortable with exercising, add resistance training to your routine, such as weightlifting, crunches, squats, lunges, or resistance band exercises. Strength training twice weekly can go a long way in improving blood sugar and fat levels.
  4. Prepare for any activity : Before conducting any form of physical activity, it is best to stretch five minutes before and after your workout.
  5. Know when not to exercise : Diabetics should avoid exercising when they experience leg pain or numbness, shortness of breath, blood sugar levels over 300 mg/dl (milligrams per deciliter), tingling, or if there are ketones in the urine.
Bonus: What Should Diabetics Eat for Dinner?

What is an ideal dinner to treat or prevent diabetes? Nutrient-dense vegetables, wild seafood, organic grass-fed meats, and chicken are great choices. These simple meal choices will help balance blood sugar and lipid levels to better manage diabetes:


Heden, T.D., et al., "Postdinner resistance exercise improves postprandial risk factors more effectively than predinner resistance exercise in patients with type 2 diabetes," Journal of Applied Physiology, March 1, 2015; 118(5): 624-634.
"Individuals with type 2 diabetes should exercise after dinner," Science Daily web site, February 18, 2015;
"Glucose Control – Exercise," Sentry Health Monitors web site;, last accessed July 8, 2015.
Murray, M., M.D., et al, The Encyclopedia of Natural Medicine (New York: Atria Paperback, 2012), 503-547.
"11 Exercise Tips for Type 2 Diabetes," WebMD web site;, last accessed July 8, 2015.

[May 21, 2019] Does It Matter When You Exercise Diabetes Forecastฎ

May 21, 2019 |

Does It Matter When You Exercise?

How the time of day you exercise affects blood glucose

By Lindsey Wahowiak March 2015 Fitness , Get Moving woman jogging


You've probably heard that exercise aids diabetes management. It's true: Moderate aerobic exercise -- the kind recommended 30 minutes a day, five days a week -- can help you lower your blood glucose.

And exercise has benefits beyond blood glucose control, says Michael Fowler, MD, assistant professor of medicine and director of diabetes outreach at Vanderbilt University Medical Center. "[Regular exercise is] highly, highly, highly beneficial in folks with type 2 diabetes ," Fowler says. It lowers risks of cardiovascular events in people with type 2 diabetes. The cardiovascular protection is less well proven in people with type 1 diabetes. "But we know that exercise, for everybody, makes our bodies more sensitive to insulin," he says. That includes any insulin the body makes or that a person injects. Greater sensitivity to insulin helps the body use it effectively to lower blood glucose levels.

You may wonder when to fit workouts in and whether the time of day you exercise makes a difference in blood glucose levels. Let's take a closer look.

Around the Clock

Whenever you can move your body -- a 20-minute walk in the morning or playing catch at night -- it's good for you and your diabetes, says Sheri Colberg-Ochs, PhD, a fellow with the American College of Sports Medicine. "The best time is when it fits in your schedule," she says.

Avoiding Lows

Of course, during and after exercise with diabetes, some people face the risk of blood glucose going too low. That's more likely to happen if you use insulin and sulfonylureas , which can put you at greater risk for lows overall.

One thing that may help you manage blood glucose during and after exercise is to set a regular time for it. A consistent exercise routine, says Fowler, can help you learn more about how exercise affects you. "What we typically recommend is that somebody does exercise at the same time -- that way things are more predictable. If it's going to cause low blood sugar, they learn how to predict it or adjust to accommodate [that]."

So let's rock around the clock to see what you might expect with regard to your blood glucose and exercise, keeping in mind, as always, that your response may vary -- from other people's and from day to day.


Some people like to rise and shine. And this can be a good time to exercise to combat what -- for some -- are the day's highest blood glucose levels. During sleep, the body typically maintains blood glucose levels by making hormones that tell your liver to release glucose. The body with diabetes often needs help from insulin or other diabetes medications to make sure the liver doesn't produce too much glucose, which can result in high blood glucose overnight and on awakening in the morning. Plus, the dawn phenomenon -- thought to be the result of a normal surge of hormones that the body produces to kick-start the day -- may also raise blood glucose levels.

Non-Insulin Users: Teresa Anderson, 45, of Myersville, Maryland, fits fitness into her schedule by working out first thing in the morning. "It's what I can stick with. That is the key," says Anderson, who has type 2 diabetes.

Insulin and Sulfonylurea Users: Talk to your doctor about what to eat before and after morning exercise and how to adjust insulin dosing and food to avoid lows.

Before Meals

Working out before a meal can be a great way to fit in some exercise. And while you may not see as much of a drop in blood glucose as at other times of day, it'll still do your body good.

Non-Insulin Users: If you don't take insulin, you probably need no extra preparation when exercising before a meal, says Colberg-Ochs. "The main effect of working out pre-meal -- other than breakfast -- may be a slightly lower rise in blood glucose after eating," she says.

Insulin and Sulfonylurea Users: If you frequently go low while exercising, it may help to exercise before meals instead of after meals, when bolus insulin or pills that cause the body to secrete insulin are the most active. Fast-acting insulin injected or pumped for your previous meal takes about four hours to be cleared from the body.

After Meals

Working out increases your body's insulin sensitivity, making it easier for insulin to transport glucose to the cells that will use it. So working out after a meal can be a good way to "use up" excess glucose after eating.

Non-Insulin Users: "I test after I exercise. I noticed that my numbers were definitely lower [after working out]," says Jacquelyn Weller, 37, of Reed City, Michigan, whose after-dinner exercise helps control her type 2 diabetes. "When I saw the numbers, I kind of celebrated a little bit. It really pushed me to make sure that I keep exercising so that I keep seeing those numbers."

Insulin and Sulfonylurea Users: Do exercise safely: Carefully monitor your blood glucose during and after post-meal physical activity to avoid surprise lows. "Generally, if you're really worried about hypoglycemia, avoid exercising within two hours of a meal," Colberg-Ochs says. This tends to be the time that injected or pumped mealtime insulin is most plentiful and active.

At Night

Any exercise, no matter the time of day, is a good idea. Be aware, however, that working out at night can interfere with your sleep -- which can affect your diabetes. The Division of Sleep Medicine at Harvard Medical School reports that the body secretes the stress hormone cortisol during exercise. That activates your brain's "alerting system." If you want a good night's rest, make sure to finish your workout at least three hours before bed.

Non-Insulin Users: Working out at night should not increase hypoglycemia risk for non-insulin users, says Colberg-Ochs.

Insulin and Sulfonylurea Users: Exercising too close to bedtime can be risky. When you're asleep, you may not feel a low coming on. So, if you're an insulin user who wants to work out at night, you'll want to carefully monitor blood glucose before, during, and after exercise and before bedtime. A snack before you go to sleep may be a good idea. You'll also want to check blood glucose in the middle of your sleep time (say, 3 a.m.), at least a few times while developing a regimen to be sure you're not going too low. Talk to your doctor about the best hypoglycemia prevention approaches for you and your routine.

The bottom line? There's no best time of day when it comes to exercise. Pick a time that works for you and just do it. As Cynthia Zuber, 39, of Minneapolis, has found, consistency is key. She prefers to walk after meals, but the timing is less important than doing it nearly every day. "For me, a walk is the perfect balm," says Zuber, who has type 1 diabetes. "If I walk three miles a day, diabetes is so much easier to manage. I always try to get that movement in."

Anaerobic Exercise

Different types of activities will affect your blood glucose in a variety of ways. We've already talked about aerobic exercise, but anaerobic exercise, or strength training, can increase your adrenaline, and that can raise your blood glucose. The same goes for interval training, including workouts such as CrossFit, and activities with short bursts of intense activity, such as basketball or hockey, says Jen Hanson, RKin, MEd, a registered kinesiologist and executive director of Connected in Motion, a Toronto nonprofit designed to get people with type 1 diabetes involved in adventurous exercise. Hanson, 31, lives with type 1 diabetes.

"When you're doing activities that are anaerobic, with short bursts of energy, the body is releasing large amounts of adrenaline," Hanson says. "That signals to your [liver] that it needs to dump large amounts of sugar into your bloodstream. Often then you'll see spikes in your blood sugar." This is because anaerobic exercise prompts your liver to produce glucagon, a hormone that raises blood glucose levels. When your body is being pushed to its limit -- not with gentle or moderate exercise, but real heart-pumping, high-intensity stuff -- its "fight or flight" reflex kicks in. "Your body doesn't want you to go low," Colberg-Ochs says. So instead, it signals your liver to kick out lots of glucose so you have energy.

"Usually, the spikes in blood glucose following high-intensity work come down on their own within a couple hours in non-insulin users," Colberg-Ochs says. "It can help to follow such activity with a lower-intensity cooldown." Insulin users, she says, should talk to their health care providers about whether or not to take insulin to correct post-exercise highs; if you take too much, you're likely to come crashing down later.

[May 21, 2019] Why Exercise Timing Matters -- But Not for the Reason You Think

May 21, 2019 |

Why Exercise Timing Matters -- But Not for the Reason You Think Nov 16, 2012 Share

A recent study published online in October 2012 in the British Journal of Nutrition (and reported on in Diabetes In Control ) attempted to address the issue of how timing of exercise relative to meal ingestion influences substrate balance and metabolic responses 1 .

In that study, ten sedentary, overweight men with a mean age of 28 years undertook an hour of moderate walking either before or after eating breakfast with their fat balance and postprandial metabolism monitored afterwards. Not surprisingly, exercising at either time (compared to just resting) significantly lowered insulin responses. Moreover, since more total fat was oxidized during the 8.5-hour period subjects were followed (which included the exercise period) and blood levels of triglycerides (blood fats) remained lower following pre-breakfast exercise in particular, the authors suggested that there may be an advantage for body fat regulation and lipid metabolism gained by exercising before compared with after breakfast.

The conclusions jumped to, based on studies like this, personally drive me crazy, especially when they are assumed to apply equally to people with diabetes (even though this study was done on overweight young men without diabetes). Despite the conclusions given in the article suggesting advantages in fat metabolism and weight loss, in actuality all the differences in calorie and substrate utilization over the ensuing 8.5 hours post-exercise were entirely accounted for by energy use during the exercise sessions themselves, not differences following the activity. In other words, walking before breakfast caused them to use (slightly) more fat during the activity -- not surprisingly -- than walking after their morning meal. When interviewed about these findings, Dr. Gill apparently said that while exercise in itself is good, any done before breakfast may be extra beneficial because it forces the body to rely on its stores of fat for energy.

Urgh!! That study was obviously not undertaken by or reported on by anyone with a background in exercise physiology. Conclusions like these perpetuate the myth that you have to "burn" fat to lose body fat, which is completely and utterly not true. While the loss of body fat undeniably requires a negative calorie balance, the operative word is calorie , not fat. Larger body fat losses result from a greater total calorie use, regardless of which fuels are used during the activity. Using a little bit of extra fat during a pre-breakfast walk is not going to make people lose more body fat -- it's the calorie deficit that contributes to weight loss! What's more, exercising when carbohydrate stores are limited after an overnight fast will likely result in a smaller calorie deficit since you are less likely to be able to exercise hard and/or long without eating first.

For moderate or harder exercise, carbohydrate is the body's preferred fuel, not fat, because the former is more fuel efficient. Having to rely more heavily on fat causes you to slow your pace and/or limit your total activity. Fat, however, is the body's primary fuel during recovery from any exercise, which spares blood glucose for glycogen restoration and amino acids (from protein) for muscle repair and more. Thus, most of the calories supplying your body's basal energy needs during the day come from fat, which is when body fat losses are greatest.

For those with diabetes, engaging in pre-breakfast exercise can actually be detrimental to blood glucose management. Anyone who exercises first thing in the morning before eating prolongs the fasting period and promotes an even greater release of glucose-raising hormones like cortisol, which in particular heightens insulin resistance pre-breakfast. In fact, a usual response for anyone with diabetes who exercises before eating breakfast is an increase in blood glucose levels, not the usual decline experiences during moderate physical activity. I can't tell you how many times I have advised people with diabetes to eat something first before engaging in early morning exercise to prevent elevations in their blood glucose levels!

When it comes to preventing postprandial spikes in blood glucose, exercising after dinner is much more effective than doing it before 2 . Others have shown that for people with type 2 diabetes, a prior meal helps enhance the glucose-lowering effect of physical activity 3 . So, when it comes to both body weight and blood glucose management, exercise done at any other time of day is likely better advice for the person with diabetes than exercising in a fasted state first thing in the morning. Remember, you do not have to "burn" fat during exercise to effectively lose body fat!

  1. Farah NMF, Gill JMR: Effects of exercise before or after meal ingestion on fat balance and postprandial metabolism in overweight men. British J Nutrition 2012 (Oct):1-11; available on CJO2012 doi:10.1017/S0007114512004448
  2. Colberg SR, Zarrabi L, Bennington L, Nakave A, Thomas Somma C, Swain DP, Sechrist SR: Postprandial walking is better for lowering the glycemic effect of dinner than pre-dinner exercise in type 2 diabetic individuals. J Am Med Dir Assoc 2009;10:394-397
  3. Poirier P, Mawhinney S, Grondin L, Tremblay A, Broderick T, Cleroux J, Catellier C, Tancrede G, Nadeau A: Prior meal enhances the plasma glucose lowering effect of exercise in type 2 diabetes. Med Sci Sports Exerc 2001;33:1259-1264

[May 21, 2019] A1C test

Notable quotes:
"... For most adults who have diabetes, an A1C level of 7 percent or less is a common treatment target ..."
May 21, 2019 |
A1C level Estimated average blood sugar (glucose) level
6 percent 126 mg/dL (7 mmol/L)
7 percent 154 mg/dL (8.6 mmol/L)
8 percent 183 mg/dL (10.2 mmol/L)
9 percent 212 mg/dL (11.8 mmol/L)
10 percent 240 mg/dL (13.4 mmol/L)
11 percent 269 mg/dL (14.9 mmol/L)
12 percent 298 mg/dL (16.5 mmol/L)
For someone who doesn't have diabetes, a normal A1C level is below 5.7 percent. If your A1C level is between 5.7 and 6.4 percent, you have prediabetes (also called impaired fasting glucose), which means you have a high risk of developing diabetes in the future.

An A1C level of 6.5 percent or higher on two separate occasions shows that you have diabetes. An A1C level above 8 percent means that your diabetes is not well-controlled and you have a higher risk of developing complications of diabetes.

For most adults who have diabetes, an A1C level of 7 percent or less is a common treatment target. Lower or higher targets may be appropriate for some individuals. If your A1C level is above your target, your doctor may recommend a change in your diabetes treatment plan.

[May 21, 2019] CounterPunch

May 21, 2019 |

May 20, 2019 Private Equity is a Driving Force Behind Devious Surprise Billings by Eileen Appelbaum Surprise medical bills are in the news almost daily. Last Thursday, the White House called for legislation to protect patients from getting surprise doctor bills when they are rushed to the emergency room and receive care from doctors not covered by insurance at an in-network hospital.

The financial burden on patients can be substantial -- these doctor charges can amount to hundreds or even thousands of dollars.

What's behind this explosion of outrageous charges and surprise medical bills? Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms.

As health reporter Bob Herman observed , acquisition of these health services "exemplifies private equity firms' appetite for buying health care providers that wield a lot of market power."

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to.

This stands in stark contrast to other health-care providers, such as primary-care physicians, who will lose patients if they are not in insurers' networks.

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

That's what happened when private equity-owned physician staffing firms took over hospital emergency rooms.

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies -- EmCare and TeamHealth -- took over hospital ERs. They found:

" that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded."

TeamHealth used the threat of sending high out-of-network bills to the insurance company's covered patients to gain high fees as in-network doctors. The researchers found:

" in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates."

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines.

This column first appeared on The Hill .

[May 18, 2019] Hemoglobin A1c (HbA1c) Test for Diabetes HbA1c Normal Levels Range

Notable quotes:
"... For people without diabetes, the normal range for the hemoglobin A1c level is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% mean you have a higher chance of getting diabetes. Levels of 6.5% or higher mean you have diabetes. ..."
"... The target A1c level for people with diabetes is usually less than 7%. The higher the hemoglobin A1c, the higher your risk of having complications related to diabetes. ..."
May 17, 2019 |
The hemoglobin A1c test tells you your average level of blood sugar over the past 2 to 3 months. It's also called HbA1c, glycated hemoglobin test, and glycohemoglobin .

People who have diabetes need this test regularly to see if their levels are staying within range. It can tell if you need to adjust your diabetes medicines. The A1c test is also used to diagnose diabetes .

What Is Hemoglobin?

Hemoglobin is a protein found in red blood cells . It gives blood its red color, and it's job is to carry oxygen throughout your body.

How the Test Works

The sugar in your blood is called glucose. When glucose builds up in your blood, it binds to the hemoglobin in your red blood cells. The A1c test measures how much glucose is bound.

Red blood cells live for about 3 months, so the test shows the average level of glucose in your blood for the past 3 months.

If your glucose levels have been high over recent weeks, your hemoglobin A1c test will be higher.

A1C and Blood Sugar A1 с (%) Average Blood Sugar (

A1C Blood sugar (mg/dL)
5 97
6 126
7 152
8 183
9 212
10 240
11 269
12 298
13 326

What's a Normal Hemoglobin A1c Test?

For people without diabetes, the normal range for the hemoglobin A1c level is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% mean you have a higher chance of getting diabetes. Levels of 6.5% or higher mean you have diabetes.

Setting Goals for A1c Levels

The target A1c level for people with diabetes is usually less than 7%. The higher the hemoglobin A1c, the higher your risk of having complications related to diabetes.

[Apr 24, 2019] Is Dentistry a Science - The Atlantic

Apr 24, 2019 |

The Truth About Dentistry

It's much less scientific -- and more prone to gratuitous procedures -- than you may think.

Arsh Raziuddin

I n the early 2000s Terry Mitchell's dentist retired. For a while, Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient 10-minute walk from Mitchell's home, in San Jose, California. Lund's practice was situated in a one-story building with clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows, round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars. To hear more feature stories, see our full list or get the Audm iPhone app.

Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell's insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and cost of the treatments did not trouble him. He had no idea that it was unusual to undergo so many root canals -- he thought they were just as common as fillings. The payments were spread out over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he might as well get them before things grew worse.

Meanwhile, another of Lund's patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s, had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly healthy, although she'd had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and telling her she needed root canals and crowns.

Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a doctor's daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent, so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the work cost her about $70,000.

In early 2012, Lund retired. Brendon Zeidler, a young dentist looking to expand his business, bought Lund's practice and assumed responsibility for his patients. Within a few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly successful, but Zeidler was making only 10 to 25 percent of Lund's reported earnings each month. As Zeidler met more of Lund's former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work -- a much larger proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn't need any additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he checked thoroughly?

In the summer, Zeidler decided to take a closer look at Lund's career. He gathered years' worth of dental records and bills for Lund's patients and began to scrutinize them, one by one. The process took him months to complete. What he uncovered was appalling.

W e have a fraught relationship with dentists as authority figures. In casual conversation we often dismiss them as "not real doctors," regarding them more as mechanics for the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are so anxious that they avoid the dentist almost entirely, and a smaller percentage have a genuine phobia requiring psychiatric intervention.

When you're in the dentist's chair, the power imbalance between practitioner and patient becomes palpable. A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like a personal failure. When a dentist declares that there is a problem, that something must be done before it's too late, who has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what's true? In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist's office -- perhaps because we both dread dental procedures and belittle their medical significance -- the impulse is to comply without much consideration, to get the whole thing over with as quickly as possible.

The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. "We are isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of the equation," says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the American Dental Association's Center for Evidence-Based Dentistry , which was established in 2007. "We're kind of behind the times, but increasingly we are trying to move the needle forward."

Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we've internalized it as truth. But this supposed commandment of oral health has no scientific grounding. Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.

Many standard dental treatments -- to say nothing of all the recent innovations and cosmetic extravagances -- are likewise not well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available are not always reassuring.

The Cochrane organization , a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants -- liquid plastics painted onto the pits and grooves of teeth like nail polish -- reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but there is only "weak, very unreliable" evidence that it combats plaque. As for common but invasive dental procedures, an increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don't clearly indicate whether it's better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.

"The body of evidence for dentistry is disappointing," says Derek Richards , the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland. "Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don't test them properly in a good-quality trial."

The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients. Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she would probably not find much to help her. When we submit to a dentist's examination, we are putting a great deal of trust in that dentist's experience and intuition -- and, of course, integrity.

When Zeidler purchased Lund's practice, in February 2012, he inherited a massive collection of patients' dental histories and bills, a mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain the alarmingly abundant dental work in the mouths of Lund's patients, he would find it in those records. He spent every weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical analyses.

The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates. Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly, and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.

Dental crowns were one of Lund's most frequent treatments. A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so its new shell will fit. Crowns typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace them every five years -- the minimum interval of time before insurance companies will cover the procedure again.

More than 50 of Lund's patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has 32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that a root canal is a "quick, comfortable procedure" that is "very similar to a routine filling." In truth, a root canal is a much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple trips to a dentist or specialist. It's also much more costly.

Read: Americans are going to Juarez for cheap dental care

Root canals are typically used to treat infections of the pulp -- the soft living core of a tooth. A dentist drills a hole through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.

Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage, known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections, which occur in a minority of cases. Yet they were extremely common in Lund's practice. In 2009, for example, Lund billed his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would almost certainly have been a memorable experience.

In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical complications, and further operations, Lund had apparently billed patients for treatments he had never administered. Zeidler was alarmed and distressed. "We go into this profession to care for patients," he told me. "That is why we become doctors. To find, I felt, someone was doing the exact opposite of that -- it was very hard, very hard to accept that someone was willing to do that."

Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell them that the man to whom they had entrusted their care -- some of them for two decades -- had apparently deceived them for his own profit.

Arsh Raziuddin

The idea of the dentist as potential charlatan has a long and rich history. In medieval Europe, barbers didn't just trim hair and shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of enemas, and tooth extraction. Barber surgeons , and the more specialized "tooth drawers," would wrench, smash, and knock teeth out of people's mouths with an intimidating metal instrument called a dental key : Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s, Thomas Berdmore, King George III's "Operator for the Teeth," described one woman who lost "a piece of jawbone as big as a walnut and three neighbouring molars" at the hands of a local barber.

Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies as a trade akin to blacksmithing ( Paul Revere was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic, nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen -- who genuinely believed in the therapeutic power of bloodsucking worms -- were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged them extra to stuff their pitted molars with homemade gunk of dubious benefit.

In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From 1839 to 1840, Horace Hayden and Chapin Harris established dentistry's first college, scientific journal, and national association. Some historical accounts claim that Hayden and Harris approached the University of Maryland's School of Medicine about adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry was of little consequence. But no definitive proof of this encounter has ever surfaced.

Whatever happened, from that point on, "the professions of dentistry and medicine would develop along separate paths," writes Mary Otto, a health journalist, in her recent book, Teeth . Becoming a practicing physician requires four years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When physicians complete their residency, they typically work for a hospital, university, or large health-care organization with substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the nation's 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically don't have the same level of oversight.

Read: Why dentistry is separate from medicine

Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral health is somehow divorced from one's overall well-being is absurd; the two are inextricably linked. Oral bacteria and the toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.

Dentistry's academic and professional isolation has been especially detrimental to its own scientific inquiry. Most major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the phrase evidence-based medicine was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based medicine, but only a handful devoted to evidence-based dentistry.

In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that curate useful resources. But its adoption "has been a relatively slow process," as a 2016 commentary in the Contemporary Clinical Dentistry journal put it. Part of the problem is funding: Because dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and industry to tackle these issues. "At a recent conference, very few practitioners were even aware of the existence of evidence-based clinical guidelines," says Elliot Abt, a professor of oral medicine at the University of Illinois. "You can publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change."

Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to advise unnecessary procedures -- whether intentionally or not. The standard euphemism for this proclivity is overtreatment . Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities" -- incipient lesions that do not require immediate treatment -- and superfluous restorations and replacements, such as swapping old metal fillings for modern resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far more than it does prevention."

"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly described his peers' penchant for " creative diagnosis " in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or 12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the procedure."

Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It was blatantly overtreatment -- drilling into teeth that did not need it whatsoever."

Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader's Digest , the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000.

A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in dentistry. In addition to dentistry's seclusion from the greater medical community, its traditional emphasis on procedure rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than $200,000. And then there's the expense of finding an office, buying new equipment, and hiring staff to set up a private practice. A dentist's income is entirely dependent on the number and type of procedures he or she performs; a routine cleaning and examination earns only a baseline fee of about $200.

In parallel with the rising cost of dental school, the amount of tooth decay in many countries' populations has declined dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the 1950s and '60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts, and veneers. It's easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and proactive treatments -- a small filling here, a new crown there -- even when waiting and watching would be better. It's equally easy to imagine how that behavior might escalate.

"If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward this attitude of 'I've got tools so I've got to fix something' much too often," says Jeffrey Camm. "Maybe it's greed, or paying off debt, or maybe it's someone's training. It's easy to lose sight of the fact that even something that seems minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad."

Arsh Raziuddin

In the summer of 2013, Zeidler asked several other dentists to review Lund's records. They all agreed with his conclusions. The likelihood that Lund's patients genuinely needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund's decisions or to explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I asked Zeidler how those meetings went, he offered a single sentence -- "I decided shortly thereafter to take legal action" -- and declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither responded.)

One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund's care, explaining what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his diagnoses and treatments were meant to keep them healthy. Isn't that what doctors do? "It makes you feel like you have been violated," Terry Mitchell says -- "somebody performing stuff on your body that doesn't need to be done." Joyce Cordi recalls a "moment of absolute fury" when she first learned of Lund's deceit. On top of all the needless operations, "there were all kinds of drains and things that I paid for and the insurance company paid for that never happened," she says. "But you can't read the dentalese."

"A lot of them felt, How can I be so stupid? Or Why didn't I go elsewhere? " Zeidler says. "But this is not about intellect. It's about betrayal of trust."

In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit, Zeidler and his lawyers argued that Lund's reported practice income of $729,000 to $988,000 a year was "a result of fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never performed." The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund's former patients, including Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They collectively reached a nearly $3 million settlement, paid out by Lund's insurance company. (Lund did not admit to any wrongdoing.)

Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney's office is prosecuting a criminal case against him based on 26 counts of insurance fraud. At the time of his arraignment, he said he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund's license, which is currently inactive.

Many of Lund's former patients worry about their future health. A root canal is not a permanent fix. It requires maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell's root canals has already failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a crown were fixed in place. "I don't know how much these root canals are going to cost me down the line," Mitchell says. "Six thousand dollars a pop for an implant -- it adds up pretty quick."

Joyce Cordi's new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday chewing. "It hurts like hell," she says. She has to wear a mouth guard every night.

What some of Lund's former patients regret most are the psychological repercussions of his alleged duplicity: the erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. "You lose your trust," Mitchell says. "You become cynical. I have become more that way, and I don't like it."

"He damaged the trust I need to have in the people who take care of me," Cordi says. "He damaged my trust in mankind. That's an unforgivable crime."

[Apr 22, 2019] The importance of physical activity

Apr 22, 2019 |

According to Boston University researchers, those people whose physical activity is 150-300 minutes a week, the aging of the brain is distant by 1.1 years for each hour of physical activity per week.

And for those who walk 7,500 steps or more per week, brain aging moves away by 1.4 to 2.2 years for every hour of physical activity per week.

[Apr 07, 2019] New York Sues Big Pharma for Opioid Crisis

Apr 07, 2019 |

In this Real News Network interview, Bill Black gives a high-level overview of the New York case against not just opioid profiteers, the Sackler family and their companies, but also other key participants, like “pain doctors” who were tied in to the Sackers’ marketing efforts.

timbers , April 6, 2019 at 8:22 am

I just want to know one thing: How many Sacklers are going to jail and for how long?

If NY wants to make the most of it's limited resources (as Black notes) then why haven't they issued arrest warrants for the Sackers and frozen their bank accounts?

Seems to me a whole lot of folks with privilege and $$$ in the news who would have be arrested on the spot had someone else (like me for example) done the same thing but w/o all that privilege and $$$ (Zuckerburg, Boeing CEO, Sacklers).

allan , April 6, 2019 at 9:16 am

Yes, more of this, please: Criminal Trial Of Opioid-Peddling Drug Company Execs Goes To The Jury [NPR]

Carl , April 6, 2019 at 8:26 am

What I hope does not get entirely forgotten in this matter is the people who need relief from pain, yet can’t get the drugs they need because doctors are so afraid to prescribe effective pain-killers, except for extreme cases, like post-op or late-stage cancers. I’m told this is the situation in New York State. Elsewhere, too?

Edward , April 6, 2019 at 1:32 pm

I wonder if the Sacklers could have gotten away with their crime if less people were killed. Suppose only 500 people were killed each year. Would the government have responded?

Iapetus , April 6, 2019 at 1:37 pm

Somehow certain aspects of this story feel vaguely familiar .

orange cats , April 6, 2019 at 3:17 pm

Oh blah blah blah. Please notice what’s absent in these “conversations” about the “opioid” crisis. The recent increase in overdose deaths is due to the (often accidental) ingestion of street fetanyl as a result of prescription opioids being restricted.

No one emphasizes the shocking absence of funding for mental health facilities; addiction research and the role of economic factors contributing to drug use; social safety nets for addicts and their children…in sum, WHY ARE SO MANY PEOPLE IN SO MUCH PAIN?
In this country you have to be sprawled unconscious in the front seat of a running car to get any help, help being prison. Jailing the Sacklers isn’t going to change that one iota.

GERMO , April 6, 2019 at 4:30 pm

The laboring class is largely being ground into hamburger. A condition of chronic, relentless pain that you can never get away from is the unchosen lifestyle for millions. That the treatment for pain (opioids) is also pretty good for despair is half an explanation for the epidemic. The other half, which is rarely mentioned, is that millions of people hurt all the time, physically or otherwise, and this is just collateral damage in the class struggle that we poor folks continue to lose.

It’s sad that the process of justice against the monsters like the Sacklers will only result in more of that pain and suffering, and to know that they won’t in the end suffer much of anything at all. The handy myth of “overprescribing” will carry the day for the higher-status class of folks who’ve never had to contend with chronic pain conditions — conditions that come about mainly because we’re so prone to being worked like dogs by psychopath bosses.

orange cats , April 6, 2019 at 5:52 pm

Thank you. I am disappointed that Bill Black and his “High-level interview” was boilerplate off-with-their-heads bunk. I admire him but do not understand why he is being recruited to opine on drug policy.

kiers , April 7, 2019 at 5:12 pm

I wonder (REALLY WONDER) if the Sacklers do not have some kind of sweet-heart insurance contract that will handle THEIR (financial) “pain” with these “suits”. Funny how A.G.s lead the chivalrous charge to “clean up” wrong-doing WELL AFTER political cover ALLOWS them to go after the elite. Funny how that works eh? Cyrus Vance gets to add to his kitty.

run75441 , April 7, 2019 at 5:15 pm

There was a major study done on the use of Opioids conducted at Boston University Medical Center, Waltham MA. The result of that study were published in a brief letter to the NEMJ.

“Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” Jane Porter; Herschel Jick; MD Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Waltham, MA.

Note the key words here are: ” We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

This particular letter (or note as some may call it) to the NEJM was cited 608 times of which 491 times was in a positive manner about addiction being rare in medical patients. The 491 (~81%) citations fail to mention the patients given Opioids were in a hospital setting and grossly misrepresented the conclusions of the letter . 72.2% cited it as evidence that addiction was rare in patients treated with opioids.

It took 37 years before another letter to the editor studied the impact of the misuse of that citation by doctors, Purdue Pharma, other Pharmaceutical Companies, etc. The authors accomplished a bibliometric analysis of the correspondence from its publication in 1980 until March 30, 2017. For each citation, two reviewers independently evaluated the portrayal of the article’s conclusions, using an adaptation of an established taxonomy of citation behavior4 along with other aspects of generalizability. The analysis which I have posted the resulting chart from it before can be found here:

The Jick and Porter letter can be found here in the Supplemental Appendix along with various quotes by doctors:

Ten years earlier or 2007, Purdue Pharma was fined $800 million by the courts after the DOJ sued them. Three executives were convicted and sentenced. From 2006 to 2015 Opioid companies spent $800 million in a 50 state strategy. The mother of Cameron Weiss found out the power of Pharma the hard way when her push for new laws in New Mexico were defeated before a vote was even taken.

In 1980 the death rate resulting from Opioid overdose was less than 1 per 100,000 and the overall death rate from Drugs was 1 per 100,000. With the introduction of OxyContin and the abuse of the Jick and Porter Letter, the death rate associated from Opioid Overdose increased to 1 per 100,000 one year later and doubled to 2 per 100,000 in 2 years. In 2015, it has soared to ~10 per 100,000.

Without knowing what has led up to the abuse of Opioids the story has always been recreational use of drugs an Opioids has caused this epidemic without ever a mention of Purdue or the other drug companies. The explosion in the use of Opioids was very deliberate and the drug companies should be held responsible for it. Now with fewer Opioid pills being prescribed, people have moved on to Heroin and Opioid derivatives. The companies lit the fuse and left with their profits.

The reason I wrote this long comment is I believe Bill Black gave this topic the short shrift. There is a lot of history on Opioid abuse and how it came to be.

[Apr 07, 2019] Kamala Harris handing of subprime mortgage crisis and opioids abuse

Apr 07, 2019 |

The Rev Kev , April 6, 2019 at 5:50 am

Do people really want the the Trump administration, the Department of Justice and the F.D.A. involved here? Bit fuzzy on the details but wasn't there a time about a decade ago when the States were getting together to sue banks for fraudulently marketing mortgages but that Obama got ahead of this movement and basically short-circuited the whole process? And the banks got a tap on the wrist as they were busy seizing homes by the millions?

If the Trump administration got involved, I would expect that Big Pharma would have to pay a few billion dollars restitution (which they, like the banks previously, could claim back on their taxes), that there would be no criminal sentences, that nobody would be convicted of a crime or have it on their record, and that Big Pharma would promise to behave better in future – starting February 30th.

Meanwhile, another thousand Americans would be dying each and every week from what Big Pharma has created. Hopefully the States will create an almighty stink with their law suits.

Cal2 , April 6, 2019 at 1:51 pm


Who will Trump's Kamala Harris be? (Mortgage fraud by banks versus Pharmafraud)

Kamala did squat in the mortgage settlement as California attorney general. What little she did get was handed to Jerry Brown to resuscitate the general fund of the state, not to homeowners cheated out of their homes.

She could have done what Scott Pruitt did in Oklahoma, which was to NOT accept the nationwide settlement. Oklahoma received 6x the national average in mortgage settlements because of that. "Chain of Title" by David Dayen.

like Corey Booker's pharma payoff, she got a nice donation for her next campaign for her probank activities, from Trump's man Mnuchin himself.

Pat , April 6, 2019 at 5:14 pm

Hey cut Kamala a break. My AG Schneiderman joined Obama's sideswipe, got pennies for NY and didn't end up in the Senate. She got more for CA, the bigger political payoff and even a run for president.

And unfortunately Justice for those abused by the corporations who benefitted is not really in our political mainstream calculations.

[Apr 05, 2019] Pelosi Accused of Deploying 'Most Dishonest Argument' Against Medicare for All by Jake Johnson

Pelosi: Sock Puppet For the Insurance Industry
Apr 05, 2019 |
described as "probably the most dishonest argument in the entire Medicare for All debate."

"People who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time. It is a complete nightmare."
-- Matt Bruenig, People's Policy Project

In an interview with the Washington Post , the Democratic leader said she is "agnostic" on Medicare for All and claimed, "A lot of people love having their employer-based insurance and the Affordable Care Act gave them better benefits."

Matt Bruenig, founder of the left-wing think tank People's Policy Project, argued in a blog post that Pelosi's statement "implies that, under our current health insurance system, people who like their employer-based insurance can hold on to it."

"This then is contrasted with a Medicare for All transition where people will lose their employer-based insurance as part of being shifted over to an excellent government plan," Bruenig wrote. "But the truth is that people who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time, over and over again. It is a complete nightmare."

To illustrate his point, Bruenig highlighted a University of Michigan study showing that among Michiganders "who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next 12 months.

"This means that 28 percent of people on an employer plan were not on that same plan one year later," Bruenig noted.

me title=

"Critics of Medicare for All are right to point out that losing your insurance sucks," Bruenig concluded. "But the only way to stop that from happening to people is to create a seamless system where people do not constantly churn on and off of insurance. Medicare for All offers that. Our current system offers the exact opposite. If you like losing your insurance all the time, then our current healthcare system is the right one for you."

All On Medicare -- a pro-Medicare for All Twitter account -- slammed Pelosi's remarks, accusing the Democratic leader of parroting insurance industry talking points:

The Speaker's alternative to the Medicare for All legislation co-sponsored by over 100 members of her caucus is a bill to strengthen the Affordable Care Act (ACA), which she introduced last week .

"We all share the value of healthcare for all Americans -- quality, affordable healthcare for all Americans," Pelosi told the Post . "What is the path to that? I think it's the Affordable Care Act, and if that leads to Medicare for All, that may be the path."

The nation's largest nurses union was among those who expressed disagreement with the Speaker's incrementalist approach.

In a statement last week, National Nurses United president Zenei Cortez, RN, said Pelosi's plan would "only put a Band-Aid on a broken healthcare system."

"National Nurses United, along with our allies, will continue to build the grassroots movement for genuine healthcare justice and push to pass Medicare for All," Cortez concluded.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

[Mar 18, 2019] Daily Dose of Aspirin Risks Outweigh Benefits

Mar 18, 2019 |

Health Editor's Note: In the past, it has been recommended that you take a low daily dose of aspirin to try to decrease forming blood clots that can lead to heart attacks and strokes. That recommendation has changed due to the risk of the aspirin causing internal bleeding which outweighs the benefits of decreasing the production of blood clots. One of the actions of aspirin is to delay clotting time, thus decrease chances of clots forming. Doctors may still want patients who are older and at high-risk for blood clots to continue to take aspirin, but that would only be for people who are not at risk of internal bleeding.

Studies have found that aspirin does not prevent first heart attacks or strokes in people who have additional health threats such as high blood pressure, high cholesterol. and smoking.

The guidelines in Europe, for any age group, are to take no preventative clotting medicines, such as aspirin. Always the best practice for your safety and health is to talk with your own healthcare provider ..Carol

CV Primary Prevention Guidelines Updated

by Crystal Phend, Senior Associtate Editor, MedPage Today

Aspirin Update

Perhaps one of the most impactful changes, Khera said, would be changes to the aspirin recommendations.

"Historically, we've always been trying to find this balance between lowering ASCVD risk, but aspirin always causes bleeding," he said. "In the past, in the right groups -- those at higher ASCVD risk -- it was felt that that balance favored taking aspirin in the right situation. Well, as of late, there have been some new studies involving data that suggest that balance has tipped the other way."

"We've had three trials in last year ( ARRIVE, ASCEND , and ASPREE ) which really have shown us that the place for aspirin has diminished in terms of primary prevention, and that bleeding will be outweighing the benefit in our modern era with all of our recommended therapies," he added.

The guidelines now recommend that prophylactic low-dose aspirin:

"Generally no, occasionally yes," was how Khera summed up the recommendations. But he also cautioned against conflating these primary prevention recommendations to secondary prevention, for which aspirin still is recommended for use.

[Mar 05, 2019] On origin of the phase There ain't no such thing as a free lunch

Mar 20, 2017 |

RC AKA Darryl, Ron -> mulp ... "...TANSTAAFL" March 20, 2017 at 04:59 AM

"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants) is a popular adage communicating the idea that it is impossible to get something for nothing.

The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have been found, but the phrase's first appearance is unknown.[1]

The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in order to entice drinking customers.

The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which helped popularize it.[2][3]

The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and it is used in economics literature to describe opportunity cost.[5]

Campbell McConnell writes that the idea is "at the core of economics".

[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and "The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]

[Feb 26, 2019] It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures.

Feb 26, 2019 |

Bragadocious , says: February 26, 2019 at 2:49 pm GMT

@animalogic I don't know if you live in the US, sounds like you don't, but one could argue that the healthcare system has already been nationalized. Consumers must shop for policies that meet Obamacare standards which include coverage for gender reassignment and other things that 10 years ago no private insurer would dream of paying for. This is a direct result of government's boot on the market's throat. (And the market likes it, based on HMO stock prices)

It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures. 15 years ago, those catastrophic plans were everywhere, and very affordable.

And to your point about providing healthcare to people who can't afford it. We already have that, it's called Medicaid. When those receiving it die, the government comes in and grabs all of their estate's assets, because they used a government program that was forced on them. Like I said, it's been taken over.

[Feb 22, 2019] How Stupid Do They Think We Are - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

Notable quotes:
"... I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement). ..."
"... Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay. ..."
Feb 22, 2019 |

How Stupid Do They Think We Are? – Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo Posted on February 22, 2019 by Yves Smith By Roy Poses , MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

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 t he 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 .


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]


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.

Disturbed Voter , February 22, 2019 at 4:26 am

Can any system of incentives work, for both the patients and the care providers? The tendency is for patients to seek professional help over over-the-counter remedies when it is unnecessary (hypochondria) and for care providers to over-test and over-medicate (avoid malpractice and promote snake oil). Either you use market-based incentives or bureaucratic incentives. And the bureaucratic incentive can be public or outsourced to commercial enterprise. There is no spontaneously self regulating system, it has to be designed-in.

Yves Smith Post author , February 22, 2019 at 6:26 am

Bullshit. Every other advanced economy had a fully or heavily government funded system. Their costs are 50-60% in GDP terms compared to ours with generally better health outcomes.

Hypochondria is present in only 1-5% of the population. That isn't a "tendency". The overtesting is due mainly to bad norms and bad economic incentives like it being perceived to be normal to have an EKG every year with your annual physical (another questionable practice in healthy people) when only people at heart disease risk need an EKG. MDs own the EKG equipment, so this is a profit center for them. Similarly, I knew instinctively that annual mammograms and annual Pap smears were overkill and I'd refuse those tests and get lectured for that. My take has now been confirmed. But those MDs were driven by bad collective beliefs as to what good medical practice was at the time, and not some personal liability fear.

As for overprescribing, again my perception is that this is more patient that MD driven (save possibly for elderly people who tend where they should be taken off certain meds for a month or two and tested to see if they are still needed). You forget that Big Pharma now advertises on TV and tells patient to ask their doctors about their wares! But the real sins like prescribing antibiotics for flus comes (as in with other cases) with patients wanting the doctor to Do Something.

I lived in Australia and MDs were very much of the "let's monitor this" (as in do nothing right now) school, which says that patients are perfectly fine with that if the doctor seems confident and also make clear that he'll change course if warranted.

MDs ought to be allowed to prescribe placebos or aspirin at real med prices with some mystery med name and have the pharmacy plan quietly rebate virtually all the price months later for the patients with real problems where meds are indicated (the problem need to run its course and the most that is called for is palliatives).

Redlife2017 , February 22, 2019 at 6:54 am

From my own experience I completely agree. In particular with your point about the Doctors being in the "let's monitor this" school of thought outside of the US.

I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement).

In the UK a doctor will never overprescribe – even if you want them to. It's just not a thing at all since there is no incentive except to be a, uh, doctor. They are trying to make sure you either get or stay healthy.

The system is built to make sure people have healthcare without weird profit incentives. They even have signs at the GP stating that if you have flu you should just rest, drink lots of fluids and stay home – don't get other people sick.

And to pre-empt someone noting that the NHS is having lots of problems – that is completely the choice of the current government (and the government in their ConDem days of 2010 – 2015). The NHS would be in much better shape if they

  1. stopped all the stealth privatisation (it's shocking what is going on) and
  2. just made sure local services were properly funded.

Amfortas the hippie , February 22, 2019 at 7:55 am

aye. the stealthy neoliberal colonisation of NIH, and all the scandinavian happy places is studiously ignored.

with my own experience with healthcare -- 6 1/2 years to get a hip to replace the literally dead one i was hobbling around on and now, all the time i've spent in and around the gleaming medical center for my wife's cancer .talking to all and sundry listing to all and sundry from wastrels at the bus stop to suits riding the elevator with me healthcare is a Right, dammit. there is no place at all for markets, privatisation or profit. it is immoral to profit off the suffering of a human being, period.

that moral argument is what will win the day even the suits acknowledge it, before passing off responsibility to the System("well, yes but we can't do anything, because the Great God Moloch must be appeased")

I am a sacrificial victim to that cruel deity. I'll be in pain for the rest of my life because i couldn't get timely care i still walk around on an ankle that is an enervated bag of gravel, since no ankle guys in texas take medicaid (and i'm kicked off that, now, too,lol)

I am thankful for my hip, hard won as it was. and i am more than grateful for the level of care my wife is getting but damn.

let these ceo's walk a mile or two in bloody shoes before they lecture about affordability and access.

their sin is gross indifference to suffering in the service of their own greed.

Susan the Other , February 22, 2019 at 12:18 pm

Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay.

This is nothing more than an obfuscation of blatant extortion. Do any of these patriotic capitalists understand capitalism? I don't think so. Too much liike a priest understanding god. Is god otherwise unaffordable, if you don't have a pious priestly middleman to do spiritual arbitrage? For a small fee, of course.

They really do think we are stupid. But they forget The Reformation. There just comes a point in time when you can't politely ignore the lies and destruction. It takes on a life of its own and is unstoppable.

This post is encouraging because there is a guy out there named Roy Poses who is connected with something called Health Care Renewal and there is another guy, Paul Waldman who works for the WaPo; and we are reminded of the wonderful Mr. Wendell Potter. And a whole nation on the march. Hope your hip and your wife are feeling better.

GF , February 22, 2019 at 12:29 pm

Here's a retweet from Bernie about the latest big pharma price gouge:

"Bernie Sanders
‏Verified account @SenSanders
Feb 20

Bernie Sanders Retweeted CNN Health

Catalyst's decision to raise the price of a life-saving drug from $0 to $375,000 is causing patients to suffer and ration their medication. Outrageous! Catalyst must immediately lower the price of Firdapse."

PlutoniumKun , February 22, 2019 at 10:37 am

A relative of mine is actually nearly through research on exactly the topic of prescribing differences between Europe and the US. He says he found a very different culture among US doctors (if and when its published I'll certainly let Yves know, it might make an interesting article or link here).

As you and Yves says, there is very little evidence of overprescribing or overtreatment in 'free' or heavily subsidised health systems. On the contrary, there is evidence of massive overtreatment in the US for people willing to pay and / or with good insurance.

Here in Ireland there were problems in hospitals because it used to be free to be an out-patient, so the poor/hypochondriac, etc., would clog up waiting rooms instead of going to their local doctor where they would have to pay. They introduced a charge solely to stop this. It was crude, but it worked. It would of course have been much better to co-ordinate charges or put a better system in place to triage real patients from those who just want a bit of sympathy.

Most GP's will tell you that about 5% of their patients represent 90% of their workload. Some people either need lots of care, or they are just demanding and go to the doctor for every little ache and pain, while others practically have to have a limb falling off before they'd go. That's just the way it is, and all systems come up with ways to deal with it.

Nearly all doctors will give prescriptions even when not needed, because they know people feel better for it. The doctors I know invariably give mild painkillers on prescription for minor things like colds and backaches. Its really a form of acceptable placebo. I'm lucky to have a really good local doctor who runs a small team who are very firm on explaining to people why they don't always need treatment or prescriptions, even to the point of it being a little annoying sometimes – he refused to burn off a wart I had some time ago, telling me just to go to a pharmacy and buy an over the counter freeze tab. And when I had a diagnosis for mild arthritis in my hip he told me to walk lots and eat natural anti-inflammatory foods – again, no prescription, even something very mild. He seemed surprised that I didn't argue the point.

That said, being strict on prescriptions can backfire. I know of a young man who died from a rare bone cancer. He was from a very poor background and looked like a typical junkie – pale skin, skinny, Nike sweat pants (he wasn't, he just looked like one). His doctor thought he was trying to scam opiates and told him the pain was all in his head.

He was a little bit innocent and believed her.

It was when he literally collapsed while visiting his girlfriend in hospital that he was examined and diagnosed – it was too late by then.

Carla , February 22, 2019 at 12:05 pm

Yves, thank you so much for calling bullshit on Disturbed Voter's comment. After spending more than two decades as a single-payer supporter, I cannot improve upon your response.

Disturbed Voter , February 22, 2019 at 12:33 pm

i work in medicine, do you? Mind you, you can have single-payer or Medicare-for-all but it isn't free (not free in Cuba or other locations).

And medical care will always be triaged on some basis so expect delay or denial of care.

What you see is dishonest accounting, moving costs from one column to another, and hiding the change.

And providers won't work for free either, unless you intend to enslave them. I am happy France etc has good open access care. You might ask how that is done, it isn't magic. The answer is, they pay high taxes, and don't spend that on things they don't want (like endless warfare). As far as drug prices go, Americans subsidize the cheaper prices found elsewhere (not that I agree do this).

AdamK , February 22, 2019 at 12:35 pm

+100000. It is also very common to create a package of services that are provided by the government insurance and leave the rest to private insurance. This package is revised every few years according to scientific reviews and adds or drops services. Plastic surgeries are out unless there's significant affects to the person'e quality of life. If a patient is interested in an experimental, or not proven, innovation, he can shop for it himself as long as there's solution that is covered. The same way private insurance deals with such cases presently. As for meds, with big data you can pinpoint to a patient that over uses or a physician who over prescribes, and use this info for integrative medicine purposes to optimize the use of meds to better results. Those methods do not go well with the healthcare industry of course. No one now has an incentive to cut services or meds.

In general every method has it wastes and frauds which cannot be quantified in advance, the issue here isn't just cost, it is first and foremost MORAL.

Mark , February 22, 2019 at 6:04 am

As a non American, I find it quite bizarre when claims like this are made. Universal health care and free/affordable quality education is available in many countries that are far less prosperous than the United States.

If only the US could look outside it's bubble and take a few hints from how things are done elsewhere. However being the "leader" of the "free world" seems to make the USA blind to looking outside its own sphere for how things could be done better.

(Not that the US is alone here. But it probably is one of the stronger examples.)

notabanker , February 22, 2019 at 7:30 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

Americans do live in bubbles, and within the US there are bubbles, the country is so vast and it's media is captured. I find it encouraging when people like yourself speak up and call bullshit. I've seen some of Sanders healthcare threads on twitter completely ratio'd with Canadian, British and Aussie's calling BS on the US propagandists that try to attack their systems. We need more of that.

Kurtismayfield , February 22, 2019 at 9:49 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

You have to consider their news sources as well.. my theory is that the only point of the 5 and 6 O'clock news is to feed into middle class anxiety or advertise a product. The corporate run media wants people scared and to buy buy buy. I would love to see a politician start a campaign where they discuss 20 different country's health care systems that are better and cheaper than ours, and see how deafening the silence will be from the corporate media.

As I have said here many times before, just get someone to propose the Swiss system . Anyone that argues that the Swiss are some bastions of communist thought can be laughed at entirely.

notabanker , February 22, 2019 at 11:36 am

I did mention the media being captured. And unlike the UK, there is no European influence to counter / add breadth to the BBC. Brits and Europeans have a far more global-centric view of things, if for no other reason than geography.

Phacops , February 22, 2019 at 10:01 am

Having to work in other countries provides a swift reality check regarding ways of social organization and doing things. I count such experiences as saving me from believing conservative propaganda here in the US.

notabanker , February 22, 2019 at 11:54 am

I am so very glad my kids spent crucial formative years outside of the US. It's the best possible gift I could have ever given to them.

Phacops , February 22, 2019 at 9:53 am

What do you expect for a people who actually hate to travel except for pre-programmed experiences or resorts walled off from the surrounding community? That, and the lack of adequate holiday time to even enjoy their own country. I don't wonder at the ignorance of the American public about better ways of providing human services and better health outcomes, though I think some such ignorance is deliberate.

Buzz , February 22, 2019 at 12:02 pm

How very, very true Mark. I've yelled and screamed this same meme over and over to no avail. Look around, we're not the only country on this planet and we DON'T always have the right answers !

Grant , February 22, 2019 at 12:40 pm

On so many issues though in this country, when we talk about the "US", we should be clear about what we are talking about. The opinions of rich people in the media, rich and corrupt politicians, strongly ideological people with a class bias that are appointed by politicians, and paid propagandists and "think tanks" don't constitute the country. I don't think that those groups have anything to learn about other countries because I think most of them are fully aware that they are not being logically factual or honest in what they say on healthcare, the critiques they give of single payer, etc. Some people maybe are (willfully) ignorant, but I think most of it is gaslighting. It doesn't matter that every single payer system has lower overhead, is more efficient, has far less social costs, is cheaper as a percentage of GDP and on a per capita basis. It doesn't matter the reasons why this is the case. There was a WHO study in 2010 that showed that administrative overhead in private systems around the world is three times higher than overhead in public systems, and why that is the case. It doesn't matter how many studies show massive aggregate savings from adopting single payer here. The data on overhead with traditional Medicare versus private insurance, polls showing that the public parts of the healthcare system (the VA, Medicare, Medicaid) are all more popular than private insurance or things like the Rand study showing that care at VA hospitals are often better than the care veterans get at private healthcare providers. None of it matters, if any person on TV actually cared about factual accuracy on stuff like this, they wouldn't be on TV. Someone else that was willing to manipulate people and lie would be in their place, and they would be paid well to do so instead of them. You can't tell me that Jake Tapper isn't fully aware of what he is doing when he "fact checks" single payer like he has done.

The public, however, does seem to get it, especially when things are described accurately to the public. Kaiser does polls, they are opposed to single payer, and so they frame their questions in really biased ways. For example, they will ask, would you support single payer if it raised taxes? Well, some respondents say not, although there is still majority support. Beyond the MMT arguments of not needing to raise taxes, let's just assume that we are trying to make single payer as revenue neutral as possible, for arguments sake. Wouldn't a more accurate question be, would you support single payer if it raised taxes, but the tax increases were more than offset by a reduction in out of pocket expenditures? Polls show strong majorities of the country support single payer, and that is with very little of those in power and with big microphones supporting the idea. We all know the studies showing the large gap between popular opinion and what the state does on policy. Like every other issue, people want one thing, and worthless people in power want another, and our system doesn't make it so that those worthless people are really directly controlled by us collectively nearly as much as donors and other interests control them.

greg , February 22, 2019 at 6:34 am

Since it is becoming increasingly obvious that our current management team of wealthy white males are both too venal and too incompetent to sustainably manage a global economy, perhaps we should start looking for alternatives.

It is delusional to think that US healthcare, or any of the problems which beset both the United States and the world, will be effectively dealt with as long as they are in charge.

It is unreasonable to expect that the over exploitation of natural resources, or sustaining the environment, addressing global warming, and so forth, will happen under their management. This is simply because they are the ones who control the earth's resources, and they are the ones who most profit from their unregulated exploitation and destruction.

It is unreasonable to expect that pollution will be effectively dealt with, because the wealthy make a profit from every ounce of pollution, and every scrap of litter, that has ever been, or will ever be, produced.

Every ounce of CO2 produced, is profit for some wealthy businessman.

Overpopulation is profitable for the wealthy. It both expands their market for goods and services, and lowers their price for labor.

Have you not noticed that we have been aware of all of these problems for over 50 years, and nothing has actually been accomplished with any of them?

Nothing effective will be done, with any of these problems, while they are in charge. It's all been talk, talk, talk, and from the wealthy, always the seeds of confusion and division.

Once a problem has been solved, it is no longer an opportunity for profit. As long as a problem festers, there is money to be made.

Every cost imposed on society is a profit opportunity for someone with wealth and power. There is money to be made, as civilization declines and collapses.

Mac na Michomhairle , February 22, 2019 at 9:23 am

You seem to start of suggesting that things would be fine, if it were not for wealthy white males being in charge.

That is a peculiar perspective that appears to attempt to divert attention from the actual horrifying system itself, and divert potential energy from attempts to change that system, to focus on a mere feature of the system.

As though, if an investment house screwed over my parents, I devote myself to bettering the world by fighting the men of Connecticut wherever I encounter them, because the house agent who was point person was from Connecticut.

If individuals in the system stand to profit from it, of course they have a stake in its continued existence; any individuals do.

Mike Mayer , February 22, 2019 at 7:39 am

Why don't businesses in the USA want to have the burden of providing health insurance taken away from them? It is a cost they bear because they need to find, negotiate, buy and administer the health plan. I am surprised most businesses are not lobbying to have the government provide it.

voteforno6 , February 22, 2019 at 9:44 am

On the other hand, the system of employer-based health insurance does offer additional ways for employers to keep the serfs in line.

rd , February 22, 2019 at 10:50 am

I tend to align with incompetence and neglect in lieu of conspiracy theories if the former can explain it, because it takes a lot of effort and smarts to pull off a conspiracy and both of those are usually in short supply across a large population.

I think we have most companies for whom the health insurance system is just something they have to have and they just go along with the flow because their competitors based in the US have similar costs.

The one organized group on this is the healthcare industrial complex that are lobbying against any nationalization type of change and even want to get more into the VA and Medicare than they already are. This IS their business and they are focused on it like a laser beam. so the conspiracy theory works for their sector.

BTW – I am surprised that the inexpensive healthcare in the rest of the developed world hasn't been a talking point of Trump's as a "subsidy" to their businesses justifying retaliatory tariffs by the US. The difference between what the US and the rest of the developed countries spends on healthcare is bigger than the entire US military budget as a percent of GDP, never mind the delta between US military spending and the other G-20 countries. So if we could drop our health care per capita spending to a bit below Switzerland's (next highest), we would have paid for the entire US military budget. If we could drop it down to Canada's level, we would have saved a year and a half's US military budget every year.

And "American Exceptionalism" pretty much ensures that nobody will look outside the US borders for solutions. If we are doing it, then it must be the best way. End of story. No further research required.

jrs , February 22, 2019 at 1:03 pm

besides the fact that it only makes a little bit of sense even as a conspiracy theory, a few people work just for healthcare and would retire otherwise (they are of course comparatively well off it goes without saying, and yes they SHOULD be able to retire, make room for those who actually NEED to work!).

But most work for survival day to day and if healthcare comes with it that's great, but many work without any form of employer provided healthcare at all (because they still need money to survive). I've heard 30-40% of the working population has NO employer provided healthcare. The serfs are still kept in line just by even more basic needs like food, shelter, and climate control, or they wouldn't show up for such jobs, but of course they do.

tegnost , February 22, 2019 at 9:59 am

IMO it's because they like the captive employees who won't quit because health care

Jim Thomson , February 22, 2019 at 12:51 pm


antidlc , February 22, 2019 at 10:18 am

As mentioned by other posters, companies want to use healthcare to keep employees captive. They don't want employees to leave for smaller firms or start their own companies. It's a way to limit competition.

Companies also have a vested interest in keeping the employer-based insurance model:

They want to be able to use your medical history to decide whether to hire or fire you. The video is quite alarming.

oaf , February 22, 2019 at 8:00 am

" the financial health of the insurance industry"

Perhaps Government should mandate the profitability of all sectors of the Economy
..or justify why they pick *favorites*

Got to keep the trough full; that's an important pig!

oaf , February 22, 2019 at 8:17 am

lest we throw out the Baby with the bathwater; let's bathe in it a while longer!

zagonostra , February 22, 2019 at 8:19 am

> 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.

Unfortunately, I think in the aggregate both are true: They are not stupid, rather cunning and evil, we are stupid, or rather easily manipulated by a very sophisticated propaganda machine that goes back to Edward Bernays. If you repeat a lie often enough it doesn't matter if it's true or not, and by the processes of association (socialism/Venezuela) we are wired in ways that makes us susceptible to blaring lies (some of Koestler's works come to mind).

There has to be a tipping point where enough people have built up defenses to the propaganda that enable "we" to go after the bloody bastards.

tegnost , February 22, 2019 at 10:16 am

I think it's less a matter of defenses and more the numbers game, the PTB have been pretty successful winnowing the field. Say a 1000 people work in an industry, someone of those 1000 figures that 100 of those can be replaced (h1b, computers, undocumented immigrants) but the amount they charge stays the same, or more likely is increased to reflect the leaner machine being more productive. Big bonus to top guy. Then it's well we have 900 employees, we could do the same with 700 employees etc and on down the line. This has worked really great for the 40 years since reagan. Add crippling student loan debt, winnow out some more people as they have been effectively neutered, basically only able at best to maintain as a steadily depreciating labor unit (hmmm, we need that persons shoes to touch the ground in a medical establishment so the gov can pay us, since that poor schlub obviously can't, thanks ACA, and once again imo, the whole reason for the medicaid aspect of the ACA) the end result is fewer and fewer successful lives being led, and more and more precarious lives being led. In 2016 the dogs wouldn't eat the dogfood. Nothing about the numbers have changed so the dogs are going to be more grumpy and indeed some of those dogs which sat on the sidelines last time might be grumpy enough to vote in 2020.

katiebird , February 22, 2019 at 8:39 am

It seems like there is a logical fallacy somewhere in this story. .

Arizona college student could die because she can't get copies of her medical records

The files are locked away in a repossessed electronic-records system while creditors of bankrupt Florence Hospital at Anthem and Gilbert Hospital bicker over who should pay for access to them.


The medical records are the only thing standing between her and a lifesaving surgery by a top physician at Johns Hopkins Hospital.

The doctor has refused to perform the operation without a complete understanding of Secrist's health history, including what her pancreas looked like when she was originally diagnosed, she said.

Every week that goes by, the danger increases of another attack of acute pancreatitis that could cause her organs to shut down.

"Without those records, we can't go forward. We can't make me better," said Secrist, who lives with her parents in Florence. "Having my life, practically, in the hands of a judge and people I don't even know, who don't even know my situation, it's upsetting."

Secrist and her primary-care physician sent letters this week to Maricopa County Superior Court urging swift release of her records. Federal and state law require medical facilities to send patients copies of their medical records within 60 days of a request.

taunger , February 22, 2019 at 9:00 am

Thank you for this post that clearly identifies the logical fallacies. This can be useful in conversations #fieldwork

Norb , February 22, 2019 at 9:04 am

In the long run, Medicare-for-all lays the groundwork for a more healthy and productive society. Healthy citizens require less healthcare, so there is potential savings over time. Healthcare is most efficient when built around a healthy society. But healthy citizens must be the primary goal, not some abstract argument about affordability and jobs protection. The jobs created by the system must be oriented toward societal health, not the profit generation for a few plutocrats. No wonder they are bemoaning the cost- they have been impoverishing the citizenry for 40 years and sooner or later that bill has to be paid.

The plutocrats, always attempting to hide their true motives, now seek to obfuscate their abject disdain for working people by using arguments of cost to continue restricting access to healthcare. Their inhumanity must be driven home and called out, but the social discourse is still in "polite" mode. Using the term 'stupid' to describe the plutocrats falls in this category. They know exactly what they are doing, and are given a social pass to continue acting in an inhumane and antisocial manner. Chants of USA USA are obscene in this context. The longer this trend continues, only decline can result.

If people are not responsive to a moral argument, the argument for comparative costs is the strongest one that needs to be constantly driven home. We are already paying- and as pointed out, will be paying much more in the future for less. Everyone can understand that and can see it in their own pocketbooks.

The moral bankruptcy of the current leadership must be called out. The propaganda bubble that Americans live enshrouded in is showing signs of weakness. That bubble will burst when pricked from forces outside the impirum- and there are many- failure is everywhere and the rest of the world is not as delusional as most Americans.

a different chris , February 22, 2019 at 9:19 am

Do these billionaires realize that, in this case the word "unaffordable" specifically means "go die"? Wow.

bassmule , February 22, 2019 at 9:27 am

As Lambert has frequently pointed out, NeoCon policy regarding health is this:

1. "Because markets!'
2. "Go die!"

voteforno6 , February 22, 2019 at 9:46 am

That's NeoLib The NeoCons are the ones who want to bomb everything, everywhere, because America.

polecat , February 22, 2019 at 11:19 am

Put the two together, and you have two wretched greedy fingers locked in avaricious embrace !

JBird4049 , February 22, 2019 at 12:15 pm

The two sets have been merging to where they would be almost the same in a Venn diagram. Almost the entire Washington establishment agrees on what is call the Washington Consensus which is cutting taxes, reducing regulations, free trade, and now apparently the Forever Wars.

Most of the differences that remains are cosmetic and focus on the social issues so that the selected base will organize, donate, and vote for them.

For example, gun control, LGBT rights, and pro-choice (abortion) for the Democratic Party and gun rights, religion, and pro-life (anti-abortion). Note that the goal is not to solve or even ameliorate any issue, but rather to inflame them so that they can be used as cover, distraction, and agitation.

Carolinian , February 22, 2019 at 9:46 am

It's all about the Benjamins–logic has nothing to do with it and never has. The largest business in my county is the hospital system which also has the highest paid CEO. And they just became even larger by buying a smaller competing hospital. Yves has pointed out how fearsome the DC health lobby is and, as cited above, the Chamber of Commerce is fully on board. There's been some excitement because announced Dem pres candidates support Medicare for all but Dem candidates always say they are for reform whereas in reality we get Hillary care in the '90s or Obamacare after both he and Hillary campaigned on the issue. Probably none of this will stop unless the economy crashes to the point that the medical complex has to accept reform and reality.

justsayknow , February 22, 2019 at 10:14 am

''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?'

I'd say Shultz gives the game away as he reveals he sees the current "system" as a make-work-make profit center.
I imagine he and Bloomberg et al have significant investments in the health industrial complex. Otherwise wouldn't it benefit all other commerce sectors to have customers with lower health costs thereby freeing up money that could be spent with them.

Eclair , February 22, 2019 at 12:22 pm

"What industry are we going to abolish next?"

Great question, Schultzie! Where were you (or your ilk) when we 'abolished' the US textile industry? Or our furniture industry? Or our electronics industry? Or our clothing industry? Or our rail car manufacturing industry?

And the jobs that went with them.

antidlc , February 22, 2019 at 10:23 am

More from Wendell Potter:

How to be ready for the health care industry lie factory

antidlc , February 22, 2019 at 10:26 am

Meet the propaganda outfit fighting against Medicare for All (podcast)

Why do we believe the things we do? Whistleblower, New York Times best selling author and founder Wendell Potter, along with millennial co-host Joey Rettino, are joined by politicians, activists, journalists and pretty much everybody else to figure it out.

Summer , February 22, 2019 at 10:26 am

I laugh when they say they are worried about "jobs" of people in the health insurance industry. They aren't worried about the jobs, but exec pay. Everytime I look up there are articles about more automation and tech in the administrative and medical pafts of the industry.
It's like Uber claiming to worry about drivers while claiming their future is driverless cars.
So a good number of people that staff the health insurance industry (talking to you non-wealthy execs) need to get on board now and get their health care covered.

There aren't too many industries that aren't salivating overways to have fewer employees and then you hear all this BS from the same industry "leaders" touting how employer based system is the only thing imaginable.

rd , February 22, 2019 at 11:12 am

BTW – latest number I can find

Canada military spending 1.0% of GDP; healthcare spending 10.4%: Total military + healthcare = 11.4% of GDP

US military spending 3.5% of GDP; healthcare spending 16.9%: Total military + healthcare = 20.4% of GDP

So between those two economic sectors, Canada has an extra 9% of GDP to spend on other priorities. No wonder they can have an inflated housing market as well as paid parental leave.

Disturbed Voter , February 22, 2019 at 12:41 pm

Exactly. To reallocate resources, you have to look at the whole picture, not just the health industry. That is a huge question. What you do with a particular allocation, is pertinent.

D , February 22, 2019 at 11:13 am

i always wonder if they are really thinking through when the say that the government (us) but that if we let patients and insurance can pay for it?? Really????

Susan the Other , February 22, 2019 at 12:45 pm

Thanks for this post, Yves. It was really good. It did all the demolishing for us. Deconstructing the whole building. I love the phrase (whether facetious or not) "argument by gibberish." I mean, it could be a necessary part of a logic curriculum – please analyze this argument for gibberish – because we were once so oblivious. So, more accurately, the pushers are now the oblivious ones. The full court press against "socialism" and "unaffordable health care" and holding up the decrepit free market isn't going to work much longer.

Hepativore , February 22, 2019 at 12:58 pm

One thing that I also hope that gets changed in the US, is combining dental care with a Medicare For all Program. It is ridiculous that people have to carry both dental and health insurance as good dental care and physical well-being are related. Left untreated, oral maladies can quickly become serious and more expensive to treat. Effective dental care is far from a vanity service.

[Feb 22, 2019] Angry Bear Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

Feb 22, 2019 |

Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

run75441 | February 21, 2019 10:00 pm

Healthcare Hot Topics This should come as no surprise as I have written on the topic of Healthcare Costs and Its Drivers before. In particular, the overriding statistic from an earlier post was 50% of the increase in healthcare costs was due solely to price increases between 1996 and 2013 (JAMA, Factors Associated With . . . . Adjusting for inflation, "annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased from $1.2 trillion to $2.1 trillion or $933.5 billion between 1996 and 2013." This was broken down into 5 fundamental factors contributing to rising healthcare costs.

– Increased US population size was associated with a 23.1% increase or $269.5 billion
– An aging population was associated with an 11.6% increase or $135.7 billion
– Changes in disease prevalence or incidence (inpatient, outpatient, ED) resulted in spending reductions of 2.4% or $28.2 billion
– Changes in service utilization (inpatient, dental) were not associated with a statistically significant change in spending
– Changes in service price and intensity were associated with a 50.0% increase or $583.5 billion.

Five fundamental factors (Population size, Population aging, Disease prevalence or incidence, Service Utilization, and Service Pricing) were collectively associated with a $933.5 billion increase in annual US health care spending between 1996 through 2013. Represented pictorially, stated objectively, and categorized numerically, I can not make it any more obvious.

Some Explanation

The change in disease prevalence or incidence was associated with a spending reduction of 2.4%, or $28.2 billion while the change in service utilization did not result in a statistically significant change in spending. Said another way, these two factors had little or no impact on the rising cost of healthcare.

The increased healthcare costs from 1996 to 2013 were largely related to Healthcare Service Price and Intensity and secondarily impacted by Population Growth and Population Aging in order of impact. The bar chart reflects all of the impact in changes.

So the aging tsunami of baby boomers has not hit yet and population growth has not greatly impacted the results of this study. In patient stays at hospitals are down as well as out patient use of facilities. The big issue is the change in pricing for inpatient hospital stays and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Viovo, and the infamous Epipens as well as others are now more expensive. This study points to pricing for pharma and service as the issues.

An example?

There is a tendency to challenge the lifestyle practices of people who indulge in too much. One factor did come out in the increased cost of healthcare. The increase in annual diabetes spending between 1996 and 2013 was $64.4 billion of which $44.4 billion of this increase was pharmaceutical spending. Said another way, two-thirds of the increase in treating diabetes was due simply to the increased pricing of pharmaceutical companies.

And yes, there should be time spent on changing habits where it can be changed and providing the means to do so. However, in 1996 Eli Lilly's Humalog was $21 per vial. By 2017, the price increased to $275 (700%) for a vial which equates to a one-month supply.

Why has the cost of Humalog increased? "The truth is the improvements in new formularies of old versions which are marginally different, and the clinical benefits of them over the older drugs have been zero." Just like slapping "new and improved" on the labels of food products with a change of ingredients (which qualifies under USDA and FDA labeling regs)., pharmaceuticals can play the same game and they do.

As the article ("Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years ") explains, "most patients do not pay the full cost/price of a drug up front and absorb their portion of the cost via an increase in monthly healthcare premiums." This leads to pharmaceutical companies charging as much as the U.S. insurance companies will let them. Both parties profiting from increased prices. Perhaps Alex Azar the Secretary of Healthcare can explain it better as he was an officer of Eli Lilly when Humalog began its ascend?

Another Study via Health Affairs

A shorter time period extending one year longer than the Jama study, the Health Affairs study supports what is being said in the JAMA study. According to data from the Henry J. Kaiser Family Foundation, total health spending on the privately insured in the United States increased in real terms by nearly 20 percent from 2007 to 2014.

A more recent study funded by the Commonwealth Fund and published by Health Affairs examined other costs impacting healthcare. Commonwealth Fund supported researchers recently analyzed hospital and physician prices for inpatient and hospital-based outpatient services as well as for four high-volume services: cesarean section, vaginal delivery, hospital-based outpatient colonoscopy, and knee replacement. Its findings were as follows:

– From 2007 to 2014, hospital-prices for inpatient care grew 42 percent compared to 18 percent for physician-prices for inpatient hospital care
– For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices
– There was no difference in results between hospitals directly employing physicians and indirectly employing physicians
– Hospital prices accounted for over 60 percent of the total price of hospital-based care.
– Hospital prices accounted for most of the cost of the four high-volume services included in the study. The hospital component ranged from 61 percent for vaginal deliveries to 84 percent for knee replacements.

Sound familiar? The JAMA study looked at both in and out patient costs/prices associated with hospital services and said they were up. The Health Affairs study looks at in patient services for four high volume inpatient services stating they have increased significantly from 2007 to 2014.

What the Health Affairs study Showed

The Health Affairs study also presents a comparison of hospital pricing growth rates as compared to physician pricing growth rates. The study is only a few weeks old and I am surprised I am able to access as much information as I have. While Health Affairs admits the study is a start and more work differentiating other aspects must be done, the study suggests there are significant growth in the bargaining leverage of hospitals as compared to physicians.

If you recall Rusty "Tom" and I engaged in a number of different conversations on healthcare with one of them being hospital consolidations (2013). It is a power grab, as Rusty pointed out, for more market segment and pricing control with those having name-recognition gaining the most. Maggie Mahar also referenced the same issue.

In my own commentary On the Horizon After Obamacare (2014): As it stands and even with its faults, the ACA is a viable solution to many of the issues faced by the uninsured and under-insured; but in itself, it only addresses the delivery-half of the healthcare problem. The other half of the problem rests with the industry delivering the healthcare and the control of pricing through the inherent monopolistic power coming and pushing the industry into greater integration of delivery. As Longman and Hewitt posit,

"the message from Department of Health and Human Services stresses the vast savings possible through a less 'fragmented and integrated' health care delivery system. With this vision in mind, HHS officials have been encouraging health care providers to merge into so-called accountable care organizations, or ACOs"; "while on the other side of the Mall, 'pronouncements from the FTC are about the need to counter the record numbers of hospitals and doctors' practices merging and using their resulting monopoly power to drive up prices."

Two different messages from government, greater efficiencies in healthcare through consolidations as ACOs versus monopolistic pricing control in healthcare by large hospital and pharmaceutical corporations an unintended result. There is large amounts of inefficiencies, waste, and rent-taking in healthcare as well as in Medicare which is touted as the go-to by politicians and advocates of it. Lets not make a similar mistake, the creation of any forthcoming healthcare system must first address the costs of healthcare and then the delivery of it not ignoring the quality of the product and its outcome after treatment. Again Maggie Mahar was big on promoting this result emanating from any new system.

While Physician fees grew at a compounded annual rate of 6% for baby deliveries and 1% for office visits between 2003 and 2010, hospitals fees during a similar period grew at 17%.

A measurement of the competitiveness of a hospital within a certain area of the country is done utilizing the Herfindahl-Hirschman Index (HHI) . It has been used to measure competition in and around cities. The results of the HHI revealed an increase in the concentration of hospitals from mergers and acquisitions, going from moderately concentrated in 1990 with an HHI numeric of 1570, to more concentrated in 2009 with a HHI of 2500, and with some cities purely monopolistic at 10,000.

Rigorous action by the FTC would certainly go a long way in improving compositeness; however, the FTC has been purposely understaffed by cutting its funding. In place at the FTC is a staff 22 lawyers and economists to monitor a $3 trillion healthcare industry. It is too understaffed to take on such a large industry which would overwhelm it with legalese and paper. Maybe in the next election will bring forth the right person to take on healthcare.


Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007–14, Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen, HealthAffairs, February 2019

Zack Cooper Hospital Care Prices Rose Faster Than the Cost of Physician Services, February, 2019

After Obamacare Phillip Longman and Paul S. Hewitt, Washington Monthly, January – February 2014

Mike Kimel , February 22, 2019 5:46 am

I have the impression that it has gotten harder to see a doctor or get a prescription filled over time. A couple of decades ago either your insurance paid or it didn't. Now it seems to me that most people have stories about arguing with insurance companies. It is sort of expected to be a part of the process. Time costs like this aren't counted with a dollar value but they surely contribute to the negative experience, and they require additional admin people at both medical providers and insurance companies. That in turns leads to more documentation and paperwork, requiring even more admin people. It's one thing if the extra personnel are a force multiplier allowing more people to be serviced. It's another if they are an impediment and an added cost.

Denis Drew , February 22, 2019 11:28 am

The political forum is too "understaffed" on all topics to fight back against (a nation of) scams because of (you know what I'm going to say) the disappearance of labor unions. Late Dean of the Washington press corps, David Broder, told a rookie reporter that when he came to DC the lobbyists were all union.

Nice to get real -- math broken down -- info beginning to tell why we pay twice as much for health care as any other country. When you add the hospitals overcharging, the drug companies bleeding us literally to death and the private insurance paper work overload, maybe we are finally sorting it out, at least a bit.

likbez , February 22, 2019 3:35 pm

The relationship between hospitals and heaths insurance companies currently somewhat resembles criminal cartel.

Often hospitals perform on the patient procedures that are best paid by the insurance companies, even if they are unnecessary, or even harmful.

An epidemic of unnecessary cardiac stents insertions in the USA is a nice illustration of the trend for costly and unnecessary (or even dangerous for the patient) procedures . Hospital cardiologists are pushed by financial incentives

"chief cardiologist Steven Nissen at the renowned Cleveland Clinic noted that doctors are paid per procedure rather than on a salary basis, while the Mayo Clinic's chief of cardiology, Raymond J. Gibbons, also cited the financial incentive of performing procedures."

And only few cardiologists that practice this racket went to jail.

That somewhat resembles relations between the car insurers and the body shops ;-)

[Feb 05, 2019] Trump and His Golfing Buddies Continue Neoliberalism s Assault on the Veteran s Administration by Lambert Strether

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system . ..."
"... Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing ..."
"... "This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve." ..."
"... Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ": ..."
"... The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors. ..."
Feb 03, 2019 |

February 3, 2019 By Lambert Strether of Corrente .

With the release of new proposed eligibility rules under the VA Mission Act, we see that privatization at the Veterans Administration (VA) continues to unfold, as outlined in the neoliberal playbook , to which we have alluded before:

The stories intertwine because they look like they're part of the neoliberal privatization playbook , here described in a post about America's universities:

It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system .

Congress imposes huge unheard-of, pension requirements on the Post Office, such that it operates at a loss, and it's gradually cannibalized by private entities, whether for services or property. And charters are justified by a similar process.

(I've helpfully numbered the steps, and added 'sabotage' alongside defunding, although defunding is neoliberalism's main play, based on the ideology of austerity.)

We can see this process play out not only in public universities, public schools, the Post Office, and the TSA , but in Britain's NHS, a national treasure that the Tories are systematically and brutally dismantling .)

The political class has been trying to privatize the VA across several administrations -- " Veterans groups are angry after President Obama told them Monday that he is still considering a proposal to have treatment for service-connected injuries charged to veterans' private insurance plan" -- although it is true that the Trump administration has brought its own special brand of crassness to the project, as we shall see. As we might expect , the project has nothing to do with the wishes of veterans :

Nearly two-thirds of veterans oppose "privatizing VA hospitals and services," according to a poll released Tuesday by the Vet Voice Foundation. And some 80 percent of the veterans surveyed believe veterans "deserve their health care to be fully paid for, not vouchers which may not cover all the costs."

A plurality of veterans, or 42 percent of those surveyed, agreed with the statement that the VA "needs more doctors," according to the poll, indicating they believe the VA's problems are at least partly due to a personnel shortage [Step (1)].

Although Vet Voice is a progressive organization, the poll of 800 veterans was jointly conducted by a Democratic polling firm and a Republican one.

And the Veterans are right, because VA hospitals provide better care. Besides many anecdotes , we have this in Stars and Stripes, " Dartmouth study finds VA hospitals outperform others in same regions ":

A new study by Dartmouth College that compares Department of Veterans Affairs hospitals with other hospitals in the same regions found VA facilities often outperform others when it comes to mortality rates and patient safety.

Researchers compared performance data at VA hospitals against non-VA facilities in 121 regions. In 14 out of 15 measures, the VA performed "significantly better" than other hospitals, according to results from the study.

"We found a surprisingly high, to me, number of cases where the VA was the best hospital in the region," said Dr. William Weeks, who led the study. "Pretty rarely was it the worst hospital." "One has to wonder whether outsourcing care is the right choice if we care about veterans' outcomes," Weeks said. "The VA is, for the most part, doing at least as well as the private sector in a local setting, and pretty often are the best performers in that setting."

"One has to wonder" indeed! Be that it may, the new VA eligibility rules accelerate privatization. USA Today :

Nearly four times as many veterans could be eligible for private health care paid for by the Department of Veterans Affairs under sweeping rules the agency proposed Wednesday.

VA officials estimated the plan could increase the number of veterans eligible for private care to as many as 2.1 million – up from roughly 560,000 .

And here are the rules (apparently modeled after TriCare Prime , the military's insurance plan):

Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing , and highly functional, single payer system. So how do we get to this point? A previous iteration of the neoliberal playbook, of course!

* * *

Our story begins with the " hastily enacted " Veterans Choice Program of 2014 :

The program, which began in 2014, was supposed to give veterans a way around long waits in the VA. But veterans using the Choice Program still had to wait longer than allowed by law. And according to ProPublica and PolitiFact's analysis of VA data, the two companies hired to run the program [TriWest and Health Net] took almost $2 billion in fees, or about 24 percent of the companies' total program expenses .

More on those fees from Pacific Standard :

According to the agency's inspector general, the VA was paying the contractors at least $295 every time it authorized private care for a veteran. The fee was so high because the VA hurriedly launched the Choice Program as a short-term response to a crisis. Four years later, the fee never subsided -- it went up to as much as $318 per referral .. In many cases, the contractors' $295-plus processing fee for every referral was bigger than the doctor's bill for services rendered, the analysis of agency data showed.

Ka-ching! So, step (3) -- profit! -- worked out very well for TriWest and Health Net, piling up $2 billion in loot. ( Step (2) was a scandal of "35 veterans who had died while waiting for care in the Phoenix VHA system," step (1) being the usual denial of resources/sabotage). The VA Mission Act was the legislative response to Veterans Choice debacle. Naturally, it moved the privatization ball down the field. The American Prospect :

Only two of the 42 members on the House and Senate Veterans Affairs Committee opposed Mission last year , when it came up for a vote.

In other words, privatizing the Veterans Administration has strong bipartisan support. But:

One of those lawmakers, Bernie Sanders, the Vermont Democrat, reiterated his opposition to Mission in December.

"This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve."

Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ":

[Bruce Moskowitz, is a Palm Beach doctor who helps wealthy people obtain high-service "concierge" medical care] is one-third of an informal council that is exerting sweeping influence on the VA from Mar-a-Lago, President Donald Trump's private club in Palm Beach, Florida. The troika is led by Ike Perlmutter, the reclusive chairman of Marvel Entertainment, who is a longtime acquaintance of President Trump's. The third member is a lawyer named Marc Sherman. None of them has ever served in the U.S. military or government .

The arrangement is without parallel in modern presidential history.

Everything is like CalPERS.

The Federal Advisory Committee Act of 1972 provides a mechanism for agencies to consult panels of outside advisers, but such committees are subject to cost controls, public disclosure and government oversight. Other presidents have relied on unofficial "kitchen cabinets," but never before have outside advisers been so specifically assigned to one agency. During the transition, Trump handed out advisory roles to several rich associates, but they've all since faded away. The Mar-a-Lago Crowd, however, has deepened its involvement in the VA.

In September 2017, the Mar-a-Lago Crowd weighed in on the side of expanding the use of the private sector. "We think that some of the VA hospitals are delivering some specialty healthcare when they shouldn't and when referrals to private facilities or other VA centers would be a better option," Perlmutter wrote in an email to Shulkin and other officials. "Our solution is to make use of academic medical centers and medical trade groups, both of whom have offered to send review teams to the VA hospitals to help this effort."

In other words, they proposed inviting private health care executives to tell the VA which services they should outsource to private providers like themselves. It was precisely the kind of fox-in-the-henhouse scenario that the VA's defenders had warned against for years.

While it is true that the ideological ground for privatization was laid by the Koch Brothers , among others, the actual vector of tranmission, as it were, seems to have been the Mar-a-Lago crowd. There has been pushback against them, in the form of a Congressional request for a GAO investigation , and a lawsuit by veterans , but as we have seen, the neoliberal play continues to run.

* * *

The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors.

Then, when our children come home, we're going to send them into a health care system that's been as crapified as everybody else's (and that's before we get to PTSD, homelessness, and suicide). Surely a pitch along those lines would play in the heartland? If Sanders doesn't pick up the ball and run with it, Gabbard should.


[1] More from Sanders. Common Dreams :

[SANDERS:] No one disagrees that veterans should be able to seek private care in cases where the VA cannot provide the specialized care they require, or when wait times for appointments are too long or when veterans might have to travel long distances for that care. The way to reduce wait times is to make sure that the VA is able to fill the more than 30,000 vacancies it currently has. This bill provides $5 billion for the Choice program. It provides nothing to fill the vacancies at the VA. That is wrong . My fear is that this bill will open the door to the draining, year after year, of much needed resources from the VA.

In other words, the way to solve the problem is not to take Step 1: Give the VA the resources that it needs.

[2] I continue to believe that golf play, or knowledge of golf play, should be a disqualification for high office.

[Jan 31, 2019] Do you think that the Guardian will shortly report that Iraq's WMD were snuck out of Iraq and hidden in Venezuela all those years ago?

Jan 31, 2019 |

The Rev Kev , , January 31, 2019 at 8:08 am

Do you think that the Guardian will shortly report that Iraq's WMD were snuck out of Iraq and hidden in Venezuela all those years ago?

Colonel Smithers , , January 31, 2019 at 8:36 am

Thank you, Kev.

Please don't give the scoundrels at King's Place any ideas.

[Jan 23, 2019] Getting on beneath the vaulted sky by Chris Bertram

January 22, 2019
Early last year, I began to experience some pains in my hands. I associated them with bringing a large turkey back from the butchers. Hadn't taken the car, because parking, but it was heavier than I appreciated and I struggled with the bird as the handles of the plastic bad tore on my fingers. I went to the doctor. Tendons, probably, he said. Most likely be better in a few months.

Then in September, back from a touring holiday in France which had involved a lot of lugging of boxes and cases up and down stairs, the pain was back, worse. I lacked the strength to open cans and bottles. Some movements were fine but turning a knob or using a key sometimes -- ouch!

That's where I am, basically. A few trips to the doctor and the physio later, osteoarthritis it seems. Injections in the thumb joint helped one hand, but less the other. Typing is ok, mostly, but my handwriting is worse. On public transport I steady myself by wrapping my arm around things, since gripping with a hand might hurt. I squeeze a rubber ball from time to time, as building up the muscles supposedly compensates a bit for the damage to the joints.

Not much fun, but could be worse. And only one of many things that comes past your mid fifties (I'm sixty now). I've had more blood tests in the past three years than in the previous thirty put together. Diabetes? No, thank goodness, not yet. Blood pressure is high, if not really dangerously so yet. Swallowing statins every morning, when I remember, to keep the choresterol down.

My father died in the summer of 2017. He was in good form until a week before the end though he'd had his share of health problems over the quarter-century before and a walk to the shops and back would see him needing a rest. We shared conversations to the end. He was lively, still learning German, discussing Edith Wharton. Though we all know that death is coming, a parent going is concrete. You know that will be you soon enough, so better make the best of it and concentrate on what matters.

As I've thought more about the loss of capacity. The aches and pains. The knowledge that there are things you could do but now can't. When you really ought to take more exercise because it is good for your heart and lungs, but when there's every chance that back, knee or hip won't play nicely enough to let you.

I keep returning to an image from a TV programme about John Clare. The picture was of a man on his back with

The grass below -- above the vaulted sky.

When young the vaulting is infinitely distant, and if lucky and not disabled you can vault over obstacles yourself. But age makes the sky close in. In your forties you can see the roof even if you can't touch it. Then, later, if you stretch, your fingers graze the surface. Time comes when you have to be careful not to bang your head. Some while after you stoop and then crouch. The tunnel gets narrower too. There is less space to move and perhaps, eventually, there will be no space at all.

Share this: { 12 comments read them below or add one }

Don A in Pennsyltucky 01.22.19 at 12:02 pm ( 1 )

Statins with dinner. Ask the pharmacist.
Hoping that the pain/stiffness in knuckles since the bicycle accident (2 months ago) continues to self-resolve with OTC anti-inflammatories
Matt 01.22.19 at 12:46 pm ( 2 )
I'm sorry to hear about the hand pain. It's especially bad for people who write for a living. When I was in college, I worked part time in a hospital pharmacy. We used hundreds of bottles of normal saline solution a day. The way that billing worked, each bottle had to have a sticker on it. I'd spend my slow time taking little bottles from a box, pulling a sticker from a strip, putting it on the bottle, and returning it to the box. Within a few months, I could no longer hold a pen or a pencil in my right hand. This was before lap tops, so it was a pretty big problem for a student! I had to refuse to do that task anymore. My hands, which had been strong, still give me trouble from time to time, and get sore easily. It's not fun. I hope yours won't be a persistent problem.
JimV 01.22.19 at 12:52 pm ( 3 )
It sounds like the tennis elbow I had after a long, hard-fought tennis session in my late forties. At the end I noticed I had a death grip on the racket handle which was difficult to loosen. The next day I was trying to leave a conference room at work which had a spring-loaded door knob. I couldn't turn the knob with my right hand, and had to awkwardly use my left hand. It lasted for several months, to the point where I didn't think it would ever heal, but it did eventually. When I did finally dare to play tennis again, I used a compression band around my right forearm, which seemed to help a lot. I never hit the ball as well as I had that day, though.

On the aging thing, I never needed a doctor (that I knew of) until about the age of 67. It has been one darn thing after another since then. (I'll spare the gory details.) I might make 75 but don't expect to see 80 (which of course isn't unusual and more than I deserve). My arm-chair philosophy about it it is that if death (by aging) didn't exist, evolution would have had to invent it, which it did. Otherwise, how can a species adapt to changes in the environment by trying new gene tweaks and combinations, without drastic over-population? For new things to succeed you have to get rid of the old things.

Cervantes 01.22.19 at 2:36 pm ( 4 )
It sounds like the arthritis at the base of the thumb is the biggest problem. It was for me. I couldn't even pick up a piece of paper with my left hand without pain, and it ached constantly. There is surgery available for that, which I got, and it worked. It was quite an ordeal, and it took a year to fully recover, but I got the use of my hand back and the pain is gone. I have arthritis in the distal joints of several fingers, but that is much less of a problem.

The surgery is kind of gross -- they remove the trapezium bone and, in my case, stuff the cavity with a rolled up tendon harvested from the forearm, which eventually ossifies. You will never miss the tendons. Some surgeons use a prosthesis, either a cadaver bone or an artificial product. It's quite painful at first and you have to wear a cast for six weeks, and then undergo rehab, but in the end, for me at least, it was a complete cure. Worth considering.

Omega Centauri 01.22.19 at 3:03 pm ( 5 )
I have chronic several overuse injuries that I used to be able work around athletics wise. But now I'm 67 and they seriously limit the amount of exercise I can get. You adapt and go on. And find other ways to spend your time and energy.

JimV @67. Well if evolution was kind to us we would remain healthy and vigorous then at some random time, boom its over. If the probability of boom was not age dependent, then there would be no difference in one's prospects whether 20 or 90.

Lee A. Arnold 01.22.19 at 4:00 pm ( 6 )
Mild continuous exercise helps including muscle strengthening over your whole body but never overdo, just daily. I walk about 3.5 miles a day, hit a gym in the middle of the walk and work about 20 weight machines, very light weights.

"We used to talk about girls. Now we talk about doctors."

-- Mel Brooks, on gathering with his friends.

Birdie 01.22.19 at 5:07 pm ( 7 )
It appears that sacrificing the body is an essential to join in civilized society in any meaningful way. Nobody else thinks overwork/stress injuries/industrial accidents are a big deal, so what's the matter with you, Bub? A serious "life of the mind" demands serious couch-potatoism. We're all playing in the NFL these days, but it doesn't have to be like that.
DILBERT DOGBERT 01.22.19 at 5:19 pm ( 8 )
Getting old is not for sissies!!!
My mental image of aging comes in two forms. One, is where you start life living in a large mansion of many rooms. Then in middle age you notice that a room is missing. As you age rooms keep disappearing. The next thing you know you are living in a one room hut.
The other is when young you see a clear horizon that seems very very distant. Then you see clouds on the horizon and it seems closer. At my age, 83, I can reach out and touch the fog.
The legs are shot and the pain in my feet is increasing. This time next year I could be in a wheelchair. Other than that life is good.
I encourage my young wife, 72, to keep on keeping on. She has taken that to heart and is riding her horse, skiing, scuba diving and renewing her pilots license. I am keeping on keeping on riding my horse and electric assist bike and living vicariously through my wife's adventures.
otpup 01.22.19 at 7:29 pm ( 9 )
There are probably nutritional approaches (though your doctor will be unbelieving and vegans will be offended). But osteo-a does give indications of being both immune related and a disease of modernity. Anyway ensure adequate fat soluble vitamins (and related minerals) This may require you to eat more saturated fat than is fashionable. Also glycine, and omega 3's. Eliminate any unnecessary PUFA's.
peter 01.22.19 at 9:50 pm ( 10 )
Don A @1:

Statins with dinner + alcohol = indigestion, heart burn and vomiting.

Statins with breakfast + no alcohol = no illness and Cholesterol levels normal.

Alan White 01.22.19 at 10:56 pm ( 11 )
Thanks Chris–this certainly hit home. Since you're only 60 and still working, allow me the presumption of my own data point as one of hope. I'm 65 and just finishing my first year of retirement after nearly 40 years of teaching at a 4/4 branch of the U of Wisconsin. Like you I've experienced some health concerns over the past 15 years including mild hypertension. Since I loved my career (down to the last day in the classroom), I didn't know what to expect when I was gently pushed out of it with a generous buy-out and threats of commuting to teach part of my load (I'd done that for 10 years and detested it). What I discovered is that I had no idea how stressful even a career that one enjoys can be! Within months I had lost 15 pounds and my BP went down, even a bit below normal, with no medication. I've been active my whole life, but clearly being out of the day-to-day grind of academic prep and research made the whole difference. My hope is that when you do retire, you find these same benefits.

One exercise that I've become devoted to is the elliptical machine on my campus, which I still may use as emeritus. It does a great job putting my heart to the test without straining my knees, which feel the effects of 40 years of running.

Chip Daniels 01.23.19 at 1:38 am ( 12 )
It is a turning point of sorts, that moment when you can actually grasp the length of time ahead of you.

I'm 58 and remember how even into my 30s, the remaining time in my life seemed to stretch away into inconceivable distance. Then somewhere in my 40s, I realized that even if I lived to a ripe old age, I could actually grasp how long that remaining time was.

I could remember forty odd years ago, I could suddenly understand that forty odd years into the future, my memories of midlife would be as fresh and sharp as my memories of kindergarten were.

[Jan 21, 2019] The Social Contract According to Elizabeth Warren

Notable quotes:
"... Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares. ..."
"... Warren Supports Medicare for All Only Nominally ..."
"... Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it? ..."
"... Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope ..."
"... but only through the institutional framework of unions ..."
"... Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ..."
"... I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference. ..."
"... Non-profit health insurance Company – The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin. ..."
"... The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech). ..."
"... The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist. ..."
"... Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won. ..."
"... " Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives . ..."
Jan 21, 2019 |

Posted on January 20, 2019 by Lambert Strether New America (board chair emeritus Eric Schmidt , President the aptronymic Anne-Marie Slaughter ), a nominally center-left Beltway think tank ( funding ) " took up the mission of designing a new social contract in 2007 and was the first organization [anywhere?] to frame its vision in these terms." On May 19, 2016, New America sponsored an annual conference (there was no 2017 iteration) entitled "The Next Social Contract." Elizabeth Warren, presidential contender, was invited to give the opening keynote ( transcript , whicn includes video). Warren shared a number of interesting ideas. I will quote portions of her speech, followed by brief commentary, much of it already familiar to NC readers, in an effort to situate her more firmly in the political landscape. But first, let me quote Warren's opening paragraph:

It is so good to be here with all of you. And yes I will be calling on people. Mostly those of you standing in the back. I always know why people are standing in the back. That's what teachers do.

Professional-class dominance games aside, it's evident that Warren is comfortable here. These are her people. And I would urge that, no matter what policy position she might take on the trail, these policies and this program are her "center of gravity," as it were. Push her left (or, to be fair, right) and, like a bobo doll , she will return to this upright position . So, to the text (all quotes from Warren from the transcript ). I'll start with two blunders, and then move on to more subtle material.

Warren Does Not Understand Uber's Business Model

Or, in strong form, Warren fell for Uber's propaganda.[1] Warren says:

Thank you to the New America Foundation for inviting me here today to talk about the gig economy You know, across the country, new companies are using the Internet to transform the way that Americans work, shop, socialize, vacation, look for love, talk to the doctor, get around, and track down ten foot feather boas, which is actually my latest search on Amazon .

These innovations have helped improve our lives in countless ways, reducing inefficiencies and leveraging network effects to help grow our economy. And this is real growth . The most famous example of this is probably the ride-sharing platforms in our cities. The taxi cab industry was riddled with monopolies, rents, inefficiencies. Cities limited the number of taxi licenses

Uber and Lyft, two ride-sharing platforms came onto the scene about five years ago, radically altered this model, enabling anyone with a smartphone and a car to deliver rides . The result was more rides, cheaper rides, and shorter wait times.

The ride-sharing story illustrates the promise of these new businesses. And the dangers. Uber and Lyft fought against local taxi cab rules that kept prices high and limited access to services .

And while their businesses provide workers with greater flexibility, companies like Lyft and Uber have often resisted efforts of those very same workers to try to access a greater share of the wealth that is generated from the work that they do. Their business model is, in part , dependent on extremely low wages for their drivers.

"In part" is doing rather a lot of work, there, even more than "the wealth that is generated," because NC readers know, Uber's business model is critically dependent on massive subsidies from investors, without which is would not exist as a firm. Hubert Horan (November 30, 2016):

Published financial data shows that Uber is losing more money than any startup in history and that its ability to capture customers and drivers from incumbent operators is entirely due to $2 billion in annual investor subsidies. The vast majority of media coverage presumes Uber is following the path of prominent digitally-based startups whose large initial losses transformed into strong profits within a few years.

This presumption is contradicted by Uber's actual financial results, which show no meaningful margin improvement through 2015 while the limited margin improvements achieved in 2016 can be entirely explained by Uber-imposed cutbacks to driver compensation. It is also contradicted by the fact that Uber lacks the major scale and network economies that allowed digitally-based startups to achieve rapid margin improvement.

As a private company, Uber is not required to publish financial statements, and financial statements disseminated privately are not required to be audited in accordance with generally accepted accounting principles (GAAP) or satisfy the SEC's reporting standards for public companies.

The financial tables below are based on private financial statements that Uber shared with investors that were published in the financial press on three separate occasions. The first set included data for 2012, 2013 and the first half of 2014 The second set included tables of GAAP profit data for full year 2014 and the first half of 2015 ; the third set included summary EBITAR contribution data for the first half of 2016. .

[F]or the year ending September 2015, Uber had GAAP losses of $2 billion on revenue of $1.4 billion, a negative 143% profit margin. Thus Uber's current operations depend on $2 billion in subsidies, funded out of the $13 billion in cash its investors have provided.

Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares.

Many other tech startups lost money as they pursued growth and market share, but losses of this magnitude are unprecedented; in its worst-ever four quarters, in 2000, Amazon had a negative 50% margin, losing $1.4 billion on $2.8 billion in revenue, and the company responded by firing more than 15 percent of its workforce. 2015 was Uber's fifth year of operations; at that point in its history Facebook was achieving 25% profit margins.

Now, in Warren's defense, it is true that she, on May 19, 2016, could not have had the benefit of Horan's post at Naked Capitalism, which was published only on November 30, 2016. However, I quoted Horan's post at length to show the dates: The data was out there; it wasn't a secret; it only needed a staffer with a some critical thinking skills and a mandate to do the research to come to the same conclusions Horan did, and Uber's lack of profitabilty, easily accessible, is a ginormous red flag for anybody who takes the idea that Uber "generates wealth" seriously. How is it that the wonkish Warren is recommending policy based on what can only be superfical research in the trade and technical press? Should not the professor have done the reading?[2]

Warren Does Not Understand How Federal Taxation Works

The second blunder. Warren says:

First, make sure that every worker pays into Social Security, as the law has always intended. Right now, it is a challenge for someone who doesn't have an employer that automatically deducts payroll taxes to pay into Social Security. This can affect both a worker's ability to qualify for disability insurance after a major [injury], and it can result in much lower retirement benefits. If Social Security is to be fully funded for generations to come, and if all workers are to have adequate benefits, then electronic, automatic, mandatory withholding of payroll taxes must apply to everyone , gig workers, 1099 workers, and hourly employees.

It is laudable that Warren wants to bring all workers in the retirement system. But as NC readers know, Federal taxes do not "pay for" Federal spending, and hence Warren's thinking that Social Security will be "fully funded" through "payroll taxes" is a nonsense (and also reinforces incredibly destructive neoliberal austerity policies). I will not tediously rehearse MMT's approach to taxation, but will simply quote a recent tweet from Warren Mosler:

me title=

And if Mosler isn't good enough, here's John Stuart Mill on currency issuers:

me title=

Again, is it too much to ask that a professor do the reading? After all, MMT gotten plenty of traction, even in 2016. The Sanders staff, for example, could have been helpful to her .

Warren Supports Medicare for All Only Nominally

Warren is indeed a co-sponsor of Sanders' ( inadequate ) S1804. But read the following passages, and you will see #MedicareForAll not where her passion lies:

As greater wealth is generated by new technology, how can we ensure that the workers who support the economy can actually share in the wealth?

(The idea that workers "support" "the" [whose?] "economy," instead of driving or being the economy, is interesting, but let that pass.)

Warren then proceeds to lay out a number of policies to answer that question. She says:

Well, I believe we start with one simple principle. All workers, no matter where they work, no matter how they work, no matter when they work, no matter who they work for, whether they pick tomatoes or build rocket ships, all workers should have some basic protections and be able to build some economic security for themselves and their families. No worker should fall through the cracks. And here are some ideas about how to rethink and strengthen the worker's bargain.

So, she's not just laying out policy for the gig economy (the occasion of the speech); she's laying out a social contract (the topic of the speech). Picking through the next sections, here is the material on health care:

We can start by strengthening our safety net so that it catches anyone who has fallen on hard times, whether they have a formal employer or not. And there are three much-needed changes right off the bat on this.

I hate the very concept of a "safety net." Why should life be like a tightrope walk? Who wants that, except crazypants neoliberal professors, mostly tenured? She then makes recommendations for three policies, and sums up:

These three, Social Security, catastrophic insurance, and earned leave, create a safety net for income.

Hello? Medical bankruptcy ?[3] She then moves on from the "safety net" for income to benefits, which is the aegis under which she places health care:

Now, the second area of change to make is on employee benefits, both for healthcare and retirement. To make them fully portable. They belong to the worker, no matter what company or platform generates the income, they should follow that worker wherever that worker goes. And the corollary to this is that workers without formal employers should have access to the same kinds of benefits that some employees already have.

I want to be clear here. The Affordable Care Act is a big step toward addressing this problem for healthcare. Providing access for workers who don't have employer-sponsored coverage and providing a long term structure for portability. We should improve on that structure, enhancing its portability, and reducing the managerial involvement of employers.

Remember, this is a Democratic audience, and what do we get? "Portability," "access", and reduced "managerial involvement." That's about as weak as tea can possibly get, and this is a liberal Democrat audience. ("The same kinds of benefits that some employees already have." Eeesh.) But wait, you say! This speech iis in 2016, and in 2018, Warren supports #MedicareForAll! For example, " Health care: Supports the "Medicare for All" bill led by Bernie Sanders " (PBS, January 17, 2019). But notice how equivocal that support is. Quoting PBS again, Warren "called that approach 'a goal worth fighting for.'" Rather equivocal! And folliowing the link to that quote, we find it's from a speech Warren gave to Families USA's Health Action 2018 Conference :

I endorsed Bernie Sanders' Medicare for All bill because it lays out a way to give every single person in this country a guarantee of high-quality health care. Everybody is covered. Nobody goes broke because of a medical bill. No more fighting with insurance companies. This is a goal worth fighting for, and I'm in this fight all the way.

There are other approaches as well I'm glad to see us put different ideas on the table.

So, we have a gesture toward #MedicareForAll. But then, Warren, instead of going into detail about how #MedicareForAll would work, immediately backtracks and emits a welter of detail about minor fixes improvements, on the order of "portability," "access," and reduced "managerial involvement." (Different details, but still details). Then she moves on to Massachusetts. Read this, and it's clear where Warren's heart is:

Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation[4].

That didn't just happen because we woke up one morning and discovered that insurance companies had just started offering great coverage at a price everyone could afford.

We demanded that insurance companies live up to their side of the bargain. Every insurer participating in our exchange is required to offer plans with standard, easy-to-compare benefits and low up-front costs for families. Last year, we had the second-lowest premiums in the ACA market of any state in the country. Massachusetts insurers pay out 92% of the dollars they bring in through premiums to cover costs for beneficiaries – not to line their own pockets.

The rules are tough in Massachusetts, but the insurance companies have shown up and done the hard work of covering families in a responsible way. We have more than double the number of insurers participating on our exchanges, compared to the average across the country. They show up, they serve the people of Massachusetts, and they still make plenty of money.

Look, we still have plenty of work to do, particularly when it comes to bring down health spending, but we're proud of the system we have built in Massachusetts, and I think it shows that good policies can have a real impact on the health and well-being of hard working people across the country.

Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it?

Warren Has No Coherent Theory of Change

Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope, but let's search on "rules" and see what we come up with. More from the transcript:

But it is policy, rules and regulations, that will determine whether workers have a meaningful opportunity to share in the wealth that is generated.

Here, workers are passive , acted upon by rules, and those who create them. But Warren contradicts herself: "Lyft and Uber have often resisted efforts of those very same workers." Here, workers are active. But if workers are active in the second context, they are also active in the first! Where does Warren think change comes from? The generosity of Uber and its investors? More:

Antitrust laws and newly-created public utilities addressed the new technological revolution's tendency toward concentration and monopoly, and kept our markets competitive. Rules to prevent cheating and fraud were added to make sure that bad actors in the marketplace couldn't get a leg up over folks who played by the rules.

Note the lack of agency in "were added." Warren erases the entire Populist Movement ! She also can't seem to get her head round the idea that workers didn't necessarily play by the existing ruies in order to create new ones. And:

Workers have a right to expect our government to work for them. To set the basic rules of the game. If this country is to have a strong middle class, then we need the policies that will make that possible. That's how shared prosperity has been built in the past, and that is our way forward now. Change won't be easy. But we don't get what we don't fight for. And I believe that America's workers are worth fighting for.

Now, on the one hand, this is great. I, too, believe that "America's workers are worth fighting for." What Warren seems to lack, at the visceral level, is the idea that workers should be (self-)empowered to do the fighting (as opposed to having the professional classes pick their fights for them). Here is Warren on unions:

Every worker should have the right to organize, period. Full-time, part-time, temp workers, gig workers, contract workers, you bet.

Very good. More:

Those who provide the labor should have the right to bargain as a group with whoever controls the terms of their work .

The idea that workers themselves should control the terms of their work seems to elude Warren. This erases, for example, co-ops. More:

Government is not the only advocate on behalf of workers.

"Not the only?" Like, there are lots of others? This seems a tendentious, not to say naive, view of the role of government. More:

It was workers [here we go], bargaining through their unions [and the qualification], who helped [helped?] introduce retirement benefits, sick pay, overtime, the weekend, and a long list of other benefits, for their members and for all workers across this country. Unions helped build America's middle class, and unions will help rebuild America's middle class.

Here, at least, Warren grants workers (partial) agency, but only through the institutional framework of unions . That distorts the history. Granted, "helped introduce" is doing a lot of work, and who they were "helping" isn't entirely clear, but the history is enormously complicated. (Here again, Warren needs to do the reading.) For example, the history of the weekend long predates unions . And "bargaining through their unions" isn't the half of it. Take, for example, the Haymarket Affair . From the Illinois Labor History Society:

To understand what happened at Haymarket, it is necessary to go back to the summer of 1884 when the Federation of Organized Trades and Labor Unions, the predecessor of the American Federation of Labor, called for May 1, 1886 to be the beginning of a nationwide movement for the eight-hour day. This wasn't a particularly radical idea since both Illinois workers and federal employees were supposed to have been covered by an eight-hour day law since 1867. The problem was that the federal government failed to enforce its own law, and in Illinois, employers forced workers to sign waivers of the law as condition of employment.

Fine, "rules." Which weren't being obeyed! More from the Illinois Labor History Society:

Monday, May 3, the peaceful scene turned violent when the Chicago police attacked and killed picketing workers at the McCormick Reaper Plant at Western and Blue Island Avenues. This attack by police provoked a protest meeting which was planned for Haymarket Square on the evening of Tuesday, May 4. Very few textbooks provide a thorough explanation of the events that led to Haymarket, nor do they mention that the pro-labor mayor of Chicago, Carter Harrison, gave permission for the meeting . Most speakers failed to appear . Instead of the expected 20,000 people, fewer than 2,500 attended . The Haymarket meeting was almost over and only about two hundred people remained when they were attacked by 176 policemen carrying Winchester repeater rifles. Fielden was speaking; even Lucy and Albert Parsons had left because it was beginning to rain. Then someone, unknown to this day, threw the first dynamite bomb ever used in peacetime history of the United States. The next day martial law was declared, not just in Chicago but throughout the nation. Anti-labor governments around the world used the Chicago incident to crush local union movements.

This is how workers "helped introduce" the eight-hour day.

Yes, America's workers are "worth fighting for." But they also fight for themselves , and are fought against! Warren's theory of change -- which seems to involve people of good will "at the table" -- cannot give an account of events like Haymarket or why, in the present day, it's Uber's drivers who are also the drivers of change, and not benevolent rulemakers. Warren's views on the social contract are in great contrast to Sanders' "Not me, us."


[1] Warren is far stronger in areas where she has developed academic expertise than in areas where she has not.

[2] Google is Google, i.e., crapified, but if Warren has retracted or changed her views on Uber, I can't find it. She was receiving good press for this speech as late as August 2017 .

[3] Oddly, bankruptcy is where Warren made her academic bones. I'm frankly baffled at her lack of full-throated advocacy on this, especially before a friendly audience.

[4] Warren, by juxtaposition, suggests that Massachusetts' health insurance coverage causes it to be "the healthiest state in the nation." This post hoc fallacy ignores, for example, demographics and the social determinants of health .

[5] Warren focuses on health insurance, not health care. I'm nothing like an expert in the Massachusetts health insurance system. However, looking at this chart , I'm seeing all the usual techniques to deny access to care: Deductibles, co-pays, out-of-network costs, and (naturally) high-deductible plans. Health care should be free at the point of delivery. Why is that so hard to understand?

Burritonomics , January 20, 2019 at 5:16 pm

I quickly went over the (188 page!) report referenced in Warren's claim that "Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation". It should be noted I went in with the expressed purpose of finding something to be snarky about, and I found it.

One of the metrics under "core measures" of clinical care was Preventable Hospitalizations. As it states in the report itself: "Preventable hospitalizations reflect the efficiency of a population's use of primary care and the quality of the primary health care received Preventable hospitalizations are more common among people without health insurance and often occur because of failure to treat conditions early in an outpatient setting". Wow! With such bang up health insurance in MA, one would figure they would do great on this metric. Nope! MA ranks 37th in the country. Many more such examples can be found, I'm sure.

I have a real dislike of these "who's best" lists, regardless of topic. Rarely do they (the aggregated ratings) contain insight beyond that captured by the individual metrics.

lambert strether , January 20, 2019 at 5:24 pm

Massachusetts is #1 on mortality (though they have issues with opioids). They have median US age, so it's not the enormous Boston student population. So they're doing something right, I'm just not sold it's health insurance or, more to the point, health insurers. They do have more physicians (and psychiatrists) per capita.

Joe Well , January 20, 2019 at 8:52 pm

What is "mortality" in this case? I'm curious about this because people often casually say that US health outcomes are worse than in other countries by looking at life expectancy (which I guess is not the same as mortality), and that comparison is rarely done on a state by state basis in the US.

Massachusetts is roughly tied with the other top ten states in life expectancy, which are almost all "blue" states . Worldwide, life expectancy among highly developed countries is roughly similar, within a few years of each other . The US comes out towards the bottom (no. 31), but only by about 1-3 years.

Also amazed just now to see that Asian American and Latino life expectancy are so much higher than for white and black Americans. Does anyone know anything about that? I'm really stunned.

Usually, lower life expectancy for blacks is given as evidence of inequality, but the white-black gap (about 1-2 years) is tiny compared with the black-Latino and black-Asian gap, or for that matter, the white-Latino or white-Asian gap, which are more like 5-10 years. I'm really floored by that.

In general, looking at the numbers just now has shaken my assumptions about poor US life expectancy and also racial disparities and I'm wondering if I'm misinterpreting them.

Joe Well , January 20, 2019 at 9:10 pm

Wow, you learn something new every day.

Apparently there is something called the "Hispanic Health Paradox" that has been studied intensively for over 30 years . The biggest reason seems to be much lower rates of smoking. There also seems to be a filtering effect whereby healthier people migrate to the US. Anecdotally, I'd suggest much lower rates of alcohol and drug abuse, but the article doesn't mention that.

So, why Mass. has a relatively high life expectancy could in part be due to it having one of the earliest and most aggressive anti-smoking movements. I'm guessing historically high smoking rates (up to 50% of adults in the 1950s with huge second-hand exposure) could also account for poorer health outcomes today.

BoyDownTheLane , January 21, 2019 at 12:49 am

One of my favorite pictures (the one I have not yet taken) would have been an elevated shot of the intersection at Longwood and Brookline Avenues (379–385 Brookline Ave) at noon on a clear, sunny spring day to see the murmuration of medical staff running between appointments, lunch, rounds, etc.

The intersection is surrounded by arguably some of the finest medical institutions in the Western world (Beth Israel Deaconess, Dana-Farber, Brigham & Women's (where Atul Gawande, author of the book "Better" and the whole entire concept of positive deviance, once held court), Harvard Medical School itself with its etched-in-granite entrace to the Countway Library that reads "Ars Longa, Vita Brevis", and the Harvard School of Public Health.

The murmuration of white coats may be at that moment the greatest single concentrated density of medical excellence at one time. It is easy to scoff. I've been the recipient of bad medicine myself, but also far more high-quality, life-saving medicine. But the public health movement in Massachusetts has been around for a very long time and is supported by and engrained within governmental regulations, oversight and policy. Insurance plans covering most of the state ranked, typically and for years, #'s 1, 2, 3 and more. The Healthcare Effectiveness Data and Information Systems report out results that are painstakingly gathered, audited to improve performance. It is fair to say that a major part of the intersection between computing and medicine was born and is overseen across the river in Cambridge. Organizations that collect or audit data for health plans and providers are screened, trained and certified by NCQA ( ).

In addition, there are national, regional and state associations devoted to quality improvement and toi improvement of access. The National Association of Community Health Centers (those clinics funded Federally to serve the under-served for free or on a sliding scale) "works in conjunction with state and regional primary care associations, health center controlled networks and other public and private sector organizations to expand health care access to all in need." There are CHC's dotted everywhere around the country (albeit not enough of them), and there is a state association in almost every state. No one can ever be turned away from a CHC, especially for lack of ability to pay; the Federal government underwrites their care.

nothing but the truth , January 20, 2019 at 5:29 pm

govts can call force us to call toilet paper a pound, but i doubt they can make it worth a pound of sterling silver – if they pretend that they can produce any amount.

Brooklin Bridge , January 20, 2019 at 5:58 pm

Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ) and particularly her whole rant on the superlatives of Massachusetts insurance care (that means, care for insurance companies) , increasingly neglects health and people care as the primary concern of medicine and the people who practice it.

As an average Joe, meaning not part of the medical world, I have come across a surprising number of doctors in both social circumstances as well as health issues of my own and of my extended family, where doctors have complained about the ever worsening constraints imposed on them by insurance companies. I know at least three doctors who retired early because of it and one of them talks about it being a significant problem in keeping highly qualified doctors in general practice. From ever more ridiculously short visits, to constant refusal to cover such and such a drug, to all manner of schemes to improve patients health by overseeing and controlling what the doctor does to finding ways to monitor what the patient does; what he or she takes as medicine and exactly when and how often – cutting the doctor out of the loop completely. Improve the patient experience my *ss. It's horrible and it all comes down to ever new ways to reduce coverage – to make more money.

Perhaps I'm being a little unjust, but Warren seems fine with this "system" where the gate keepers make, "plenty of money," as long as people are going in and out of doctors' offices in countable droves as if on run-away conveyer belts. I should at least allow that many of her superlative claims are accurate (or somewhat accurate) and that there is fairly wide coverage in this state but nevertheless stress that our excellent medical facilities in Boston proper are due to historical reasons and NOT to RomneyCare.

deplorado , January 20, 2019 at 5:59 pm

Thank you Lambert, for your cogent and discerning analysis as always. I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference.

What worries me more though is Sanders's bill and why he wouldn't go all the way? Would you do an analysis of that please – will really appreciate it.


Joe Well , January 20, 2019 at 6:10 pm

The vast majority of Massachusetts health plan providers are nonprofit HMOs so I'm baffled by the idea that they are making tons of money since legally they are not supposed to.

The most obvious difference between Mass and the rest of the country is precisely the preponderance of nonprofit health plans (it's not commonly called health insurance here) and nonprofit hospitals. The idea of for-profit health plans and hospitals freaks me out.

It's worth noting that Mass health coverage seems to have gotten worse in recent years, though I don't know how much of that is due to Obamacare. High deductibles, coinsurance, confusing in-network requirements combined with poor documentation and even poorer customer service to tell you what is in-network and what is not. I just got a surprise $370 bill for a provider that supposedly was out of network even though I had checked extensively that they were in-network. That is the first time that has ever happened to me in Mass. Not to mention the confusing and unnerving notices I got the last few months saying I was in danger of losing coverage. A great big ball of Weberian beaureaucratic stress.

bob , January 20, 2019 at 8:04 pm

Non-profit health insurance Company – The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin.

somecallmetim , January 20, 2019 at 10:08 pm

Health Care Economist / Professor Uwe Reinhardt used to comment that in the current system non-profit hospitals (The Sisters of Mercy, with a token nun on their board, in his telling) were subject to the same forces as for profit hospitals.

He also said Massachusetts has the only adult health care system, and the other states are all adolescents.

johnnygl , January 20, 2019 at 9:10 pm

We've got for-profit hospitals Cerberus took the caritas network. The hospitals dominate this state. The rest of us are just living here.

johnnygl , January 20, 2019 at 9:15 pm

Special thanks to the catholic church for selling such an important institution to a monster that guards the gates of the underworld.

I bet it was to cover the costs of child predator priests.

Joe Well , January 20, 2019 at 10:20 pm

Wow, I'd missed that (moved out of state, then came back). Thanks for the update. It looks like the Catholic Church (former owner of Caritas) has further enhanced its legacy in Massachusetts. However, I believe it is still true that the hospital market in Mass. is dominated by nonprofits (albeit greedy nonprofits).

And yes, hospitals and hospital chains (e.g., Partners Healthcare, which is nonprofit) pose huge challenges to managing healthcare costs in Mass. as the numerous Boston Globe investigative series attest, by using their market power to raises prices.

My concern is when the market becomes dominated by for-profit actors, the profit-seeking, which is already bad with nonprofits, becomes even worse, especially in an ultra-expensive market like Greater Boston.

Brooklin Bridge , January 20, 2019 at 6:16 pm

I should add (if my earlier comment get's posted), it's even more surprising how many doctor's seem just fine with all the negative changes being brought about by insurance companies' intrusive quest for control and I don't mean just the ones who say nothing.

That is, some doctors seem to enjoy the vestiges of the glow of community respect and honor that once went with being a doctor all while doing almost nothing other than sheep herding patients through the office in good file while staff (not the good doctor) attend to making the visit digital and storing it away in some cloud.

Tomonthebeach , January 20, 2019 at 7:07 pm

I agree with Warren Mosler that Elizabeth Warren's apparent ignorance of MMT, much less mastery of it, makes here a lame candidate in my book. She needs to get woke pretty quickly or settle for some cabinet appointment.

Anarcissie , January 20, 2019 at 10:10 pm

Is MMT now Scripture?

ChrisAtRU , January 20, 2019 at 10:22 pm

It's more important than 'scripture' it's how sovereign fiat money actually works .

Joe Well , January 20, 2019 at 10:57 pm

You don't even need MMT. When asked how the federal government can pay for something, people can just answer, "the same way we pay for military and intelligence spending." Any politician who won't say at least this is deeply suspicious.

David in Santa Cruz , January 20, 2019 at 7:40 pm

In The Unwinding , George Packer quotes Elizabeth Warren as describing her political views thusly:

"I was a Republican because I thought that those were the people who best supported markets"

I'm glad that she's out there, I'm glad that she's talking, and we need an open and transparent nomination process, but Bernie Sanders remains the only (potential) nominee who comes close to representing my views. Good piece.

emorej a hong kong , January 20, 2019 at 7:50 pm

The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech).

The speech's date (May 19 2016), was two days after Bernie won the Oregon primary by 14%, and two days before Hillary won the Washington state primary by 5%.

Synoia , January 20, 2019 at 8:07 pm

It was going to be BS directly after this:

New America (board chair emeritus Eric Schmidt

The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist.

Synoia , January 20, 2019 at 8:11 pm

It was going to be BE after this phrase

New America (board chair emeritus Eric Schmidt,

The Eric Schmidt who took Google doen the path of spying on everybody. He has nothing to offer by centrist rhetoric. It would be very interesting in how much In-Q-Tel invested in Google.

flora , January 20, 2019 at 8:39 pm

Thanks for this post.
And thanks for the reminder that the 8 hour workday and the 40 hour workweek were not 'given' to workers, they were won by workers.

Matthew G. Saroff , January 20, 2019 at 9:48 pm

I made an a similar observation on my blog .

Compare these two quotes on Pharma looting.


Giant companies may hate my Affordable Drug Manufacturing bill – but I don't work for them. The American people deserve competitive markets and fair prices. By fixing the broken generic drug market, we can bring the cost of prescriptions down.


If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them.

This is a not an insignificant difference

Mike Barry , January 20, 2019 at 10:30 pm

The best is the enemy of the good.

Yves Smith , January 20, 2019 at 11:17 pm

Tell me what about Warren not understanding how federal taxes work, which is fundamental to formulating sound fiscal policy and spending plans, not being serious about fixing our health care system, or praising the predatory gig economy, is "good".

RepubAnon , January 20, 2019 at 11:32 pm

On a side note: self-employed workers pay more out-of-pocket into Social Security than W-2 employees. W-2 employees only pay half the Social Security tax – employers pay the other half via a "payroll tax."

The self-employed pay both the employee's half of Social Security, and also pay a "Self-Employment tax" (the employer's half of Social Security). The logic is that if you are both employee and employer, you should pay both halves.

Yves Smith , January 21, 2019 at 12:58 am

This is thread jacking, plus an economist would point out that the employer clearly is paying a net wage that reflects his awareness that he is paying the employer side of the FICA taxes.

Ape , January 21, 2019 at 12:31 am

Or lesser of two evils? There really needs to be a good discussion again about reform versus structural change without Chait-like pretensions. The question isn't just whether we'll get there in time, but whether reform even out runs reaction. Once you take out patriotic myth, it's not obvious whethervthe good in the long term is even worth bothering with.

Glen , January 21, 2019 at 12:47 am

Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won.

The Rev Kev , January 20, 2019 at 11:01 pm

I can't help but think that if you are talking about the "Next Social Contract", them you should put something in there that if you have children going hungry then something has gone wrong with your society. Not being snarky here as I believe that a fundamental purpose of society is to protect those in need. An earlier society talked about 'women and children first' and they were not too far off the mark here.

She was invited to talk about the gig economy but in reading her speech I was under the impression that she wants the Federal government to underwrite the costs of workers for corporations to ensure that maybe these workers have food to eat while working for these very same corporations. I suspect that this is the thinking behind letting Amazon workers go for Federal assistance for the sheer basics of life while Amazon makes off like bandits.

No. The way to go is to enforce corporations like this pay a living wage and not to have them count on the country to make up the difference. If they start to protest, then start to talk about looking over their accounts for any discrepancies to make them back off. That's how they got Al Capone you know. Not for being a gangster but for not paying his taxes while doing so. And do the same for mobs like Uber and Lyft and all the other corporations.

BoyDownTheLane , January 21, 2019 at 12:16 am

" Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives ."

Left in Wisconsin , January 21, 2019 at 12:38 am

Sigh. Nail hit squarely on head. The one thing I will say to Warren's credit is that she has learned in some specific ways that the world isn't invariably the pure meritocracy that is so instinctively part of her world view. That said, it seems clear there will always be plenty that she is simply not capable of seeing, so she will always say and support things that are just wrong. She will not be leading the revolution.

[Jan 19, 2019] Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market

Jan 19, 2019 |

anne , January 15, 2019 at 05:59 PM

January 14, 2019

Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market
Allowing foreign imports, authorizing Medicare bargaining, or setting prices at what other nations pay -- all good options

The prescription drug market in the United States is an incredible mess. From an economic standpoint, everything is wrong. Drugs that would sell for a few hundred dollars in a free market often sell for tens or even hundreds of thousands of dollars because we give their manufacturers patent monopolies. This leads to the sort of distortions and inefficiency that would be expected from tariffs as high as many thousands percent.

From a heath perspective the situation is no better. The huge markups give drug companies enormous incentive to misrepresent the safety and effectiveness of their drugs and to push them for uses where they may not be appropriate. This is a big part of the story of the opioid epidemic.

Cumulatively, it is a huge deal in both economics and health. We spent more than $430 billion (2.2 percent of GDP) on prescription drugs last year. These drugs likely would have cost less than $80 billion in a free market. The difference of $350 billion is almost five times the annual federal budget for food stamps. This is real money.

This is the backdrop for three bills proposed last week by Senator Bernie Sanders, along with Representatives Elijah Cummings and Ro Khanna, to address the high and rapidly rising cost of prescription drugs. The three measures provide alternative paths for reducing drug prices.

The first one, "The Prescription Drug Price Relief Act," would end the patent monopoly for any drug that sold for a price exceeding the median price in five other major countries: Canada, the United Kingdom, France, Germany, and Japan. This would allow large savings since drug prices in these countries are roughly half as much as in the United States. Drug companies would have a choice of either lowering their prices or losing their patent monopoly.

In the latter case, the competition is likely to push the price well below the levels in the five countries. While these nations do regulate drug prices, patent monopolies still let the companies charge a price that is far higher than the price that would exist in a competitive market with generic competition.

The second bill is "The Medicare Drug Price Negotiation Act." This bill would allow Medicare to negotiate collectively for the drugs purchased through Medicare prescription drug insurance. Since this program spends roughly $100 billion annually on drugs, it should have serious bargaining power.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted. Representative Billy Tauzin, who headed the Energy and Commerce Committee, which structured the Medicare prescription drug legislation, resigned immediately after the bill was signed into law to become head of the pharmaceutical industry's trade association.

The third bill, "The Affordable and Safe Prescription Drug Importation Act," is also an effort to take advantage of the fact that drugs are so much cheaper in other countries than in the United States. This bill would allow people to freely import drugs from other wealthy countries that have safety standards that are comparable to those in the United States.

This bill both highlights the sharp differences in prices between the United States and other countries and calls out one of the big lies used to justify these differences. Allies of the drug industry often claim that we cannot count on getting safe drugs from other countries, implying that countries like Canada and Germany do not protect their populations from unsafe drugs.

This is, of course, absurd. The standards in these countries are every bit as high as in the United States. And, if we think the quality of imported drugs is a problem, we all should already be very worried because many of the drugs and ingredients in drugs sold in the United States are already imported, largely from China. So the idea that we can't be assured of the safety of imported drugs is simply an industry talking point, not a real concern.

Which of these paths for reducing drug costs is best? Importation is probably the most far-reaching, since it should quickly bring our prices down to the level of other wealthy countries. As a practical matter, however, progressives should back anything that moves the debate forward.

We really need to turn the industry on its head, paying for research upfront and then having drugs sold in a free market, like paper plates and shovels. It is absurd to pay for research that has already been done, at the point when people are suffering from serious conditions jeopardizing their health or their life.

No one thinks it makes sense to pay firefighters based on the value of their work when they come to our burning house with our families inside, yet this is essentially how we pay for drug research under the patent monopoly system. In fact, the story is even worse with drugs, since typically we have a third party payer (either an insurance company or the government) who we are trying to get pick up most of the tab.

These bills would not fully solve the problem, but each would be a big step in the right direction. Sanders, Cummings, and Khanna have done a great service in pushing them forward.

mulp -> anne... , January 16, 2019 at 04:33 PM
"No one thinks it makes sense to pay firefighters based on the value of their work ..."

We value fire fighters as worthless, by not paying most fire fighters in the US.

After all, requiring the people saving your life to be paid kills jobs, so we end up with unpaid life savvers.

We should appply the same principle to people providing life saving food, the people building the roads needed to deliver life savings, the people making the vehicles used by those providing life saving services.

In fact, no one should be paid to work! Thats free lunch economics!

Sarcastic, yes.

Dean Baker meantioned nothing about costs, which are always labor costs.

Look, Keynes argued that when there were unemployed workers, and capital is scarce, government should tax and spend to pay workers to build capital.

For drugs, paying unemployed researchers to build capital, eg, life saving drugs, then taxing the drugs produced to repay the cost of developing the drugs, with so many new drugs developed, the private capital in drug factories, etc will produce so many drugs that drug prices fall to total labor costs per unit, plus the drug tax.

We know there are unemployed drugresearchers because NIH always runs out of money to pay all thre recent collage grads seeking grants to fund their hoped for job as a researcher.

Plp -> mulp ... , January 18, 2019 at 01:41 PM
Mulp what about monopoly profits my friend

Research could rise and marketing cuts pay for it

Yes there's slack created
In marketing jobs and funding entertainment of course

Plp -> anne... , January 17, 2019 at 08:40 AM
Bernie and Liz are too valuable to waste running for
The Dem nom

Leave that for a clever weather vane
Like Harris and that jersey senator

The gal from the Bronx
is another Bill Bryan

She is the future

anne -> Plp... , January 18, 2019 at 09:21 AM
The gal from the Bronx
is another Bill Bryan

She is the future

[ Funny and right and especially clever. ]

Julio -> Plp... , January 18, 2019 at 09:21 AM
Agreed completely.
Warren, in particular, makes a great senator but I doubt would make a great president.
Christopher H. said in reply to Julio ... , January 18, 2019 at 10:01 AM
Disagree, unfortunately in the American system the President gets all the attention and can spread the message.

Either Bernie or Warren would be good. I'd much prefer Bernie.

Plp -> Christopher H.... , January 18, 2019 at 01:43 PM
No problem if they win the POTUS job

Still I'd prefer AOC

[Jan 13, 2019] Libertarian wet dreams and reality of the Us healthcare

Jan 13, 2019 |

JB Nashville, Tennessee Jan. 11

@Bill - So you're willing to gamble with your own health and the well-being of any family or loved ones you have and trust in some ambulance chaser against an armada of $3000 suits? Good luck with that.

While I'm often skeptical of our government, I have ZERO faith in any corporation to do right by me.

Their only mission is to make as much money as they can, and even paying out the occasional lawsuit is a reasonable cost of doing business. The only way a capitalist entity can be trusted is if a more powerful authority is looking over their shoulder. The FDA is one of many federal entities standing between us and an indifferent group of shareholders and CEOs.

[Jan 11, 2019] Health Insurer Greed or Desperation An Odd Data Point From Cigna naked capitalism

Notable quotes:
"... It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not. ..."
"... The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home. ..."
Jan 11, 2019 |

Health Insurer Greed or Desperation? An Odd Data Point From Cigna Posted on January 9, 2019 by Yves Smith I sometimes give personal Consumerist-type anecdotes about dodgy vendor behavior in case readers have had similar experiences.

Admittedly, health insurers being difficult about paying claims is so common that they fall in the realm of "dog bites man" stories. But the elements of my latest arm-wrestle with Cigna suggest that the insurer is so eager to maximize profit and burnish its financials that it is doing the equivalent of pulling up the sofa cushions to collect change.

I've had this plan a very long time, since the early 1990s. Cigna in theory has not changed the terms (to do so, it would have to notify me and New York State) save approved rate increases. In practice it has, by among other things a few years back requiring that claims be submitted within 120 days of service. That has allowed it to engage in a new form of mischief: simply not processing some claims. No doubt the hope is that consumers won't notice, or will notice too late to get duplicate documentation and resubmit before the 120 days are up.

Mind you, for well over 15 years, I never had a single claim go astray. Now it happens with sufficiently high frequency for it to be implausible that the US Postal Service is losing so many of my letters, when other envelopes virtually never go missing. So every time I submit a claim, I have taken to recording the details necessary to locate the items in Cigna's system, as well as the mailing date.

Last July, Cigna sent a letter about a "pharmacy claim". It was a remarkably content-free document, with no reference to dates of service or any clues to allow a customer to figure out what they might be referring to, particularly since I do not have a pharmacy plan. A "pharmacy plan" is when the doctor sends a scrip to the pharmacy on behalf of a patient, and the pharmacy bills the insurer, with the patient responsible for any co-pay. My plan covers prescription drugs, including ones I get overseas (I've submitted prescription drug claims from England and Australia). I pay for the drugs and I submit for reimbursement. And until the mysterious July letter, I never had any problem with them being paid (provided, of course, Cigna didn't try claiming it had never gotten the claim).

Fortunately, because I keep good records, I could see I had sent in a claim in late June for four dates of service for less than $400 worth of meds total. The only reason the amount was that high was three of the four items were 90 day supplies.

I called Cigna and got a rep who found the four items and confirmed they were in a payment limbo and ought to be paid.

When no check had arrived by September, I called again, had the agent say that there was not reason for the claim not to have been paid, and put it in for reprocessing.

On November 28, with still no payment, I insisted on speaking to a supervisor, which it took an ungodly amount of time to reach. I started making noise about external appeal to New York state (my plan is a New York state regulated plan). She confirmed like everyone else that it should have been paid, and said the check would go out in three to five days.

Two weeks later, nothing from Cigna.

I called again. I got an agent who said the payment is pending.

By this time, steam was pouring out of my ears. I asked again to speak to a supervisor. After a 30 minute wait, I was told one would call me back. I should have known from long experience with Cigna that promises to make calls or follow up are empty, as this proved to be.

I decided to have one last go on the phone before writing the state for an external appeal. I called over the weekend. The agent said that the payment was issued on January 3, but she saw only three of the four drugs in the scans of the claims. Mind you, this was the cheapest scrip, and a shortfall versus what I should have received of about $13 (assuming that check finally arrives). But this is what this incident says about Cigna:

1. Recall that on the first call, and if my recollection serves me right, on at least one of the later calls, I confirmed the dates of the claims. The one that disappeared was the most recent in the date range, making it almost certain that I cited it most if not all calls.

This strongly suggests that the original Cigna hope was that I would not follow up adequately on their bafflegab letter, and when I did, someone went and scrubbed my record to reduce the amount Cigna would have to lay out. This is such a small amount that it would seem hardly worth the effort .which further suggests that Cigna has this sort of records-doctoring highly enough routinized to be able to do it cheaply. 1

2. Cigna has supposedly initiated payment right after the new year. Even though Cigna ought to be on an accrual as opposed to a cash accounting basis, it's not hard to infer that they kicked the payment back into a new fiscal year to flatter some sort of metric. It might not even be a financial reporting metric but some other measure that senior management and/or analysts follow.

As we said at the outset, in terms of abuses, this is small beer. But that's the point. Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me, knowing in this era when class action suits are virtually dead, that they can grift with no fear of being held to account.

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.


1 The last agent checked my records for the date of the gone-missing drug claim to see if it had somehow gotten separated from the other three and was being handled separately. She came up empty-handed. Recall that I now have a not-approved, not-noticed-as-required change to my contract of a 120 day submission limit, so disappearing that item so late in the game makes it impossible for me to resubmit that item.

Geo , January 9, 2019 at 4:09 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Well said. You're much more thorough and persistent than I am. I'm their target dupe that won't notice such things and just accept that it was my fault when I do notice. Very insightful read. Thanks so much!

WestcoastDeplorable , January 9, 2019 at 3:17 pm

Sorry to read of your problems, but Insurance companies aren't the only category screwing with the details; I recently transferred a balance to U.S. Bank on one of those "zero interest for 12 month" deals. In about 2 months after the transfer, all the sudden I get a late notice from them, then realize I didn't receive a statement (which was about 10 days late). And they laid a $39 charge on the account, which I was able to get waived with a trip to my local bank. Little did I realize this "late pay" also resulted in nixing the "zero interest" deal, and they levied the full interest on the balance.
Needless to say, I transferred the balance elsewhere, but seems to me lots of companies are gaming the mailing of statements to pad their coffers.

campbeln , January 9, 2019 at 3:53 pm

I had a good one with Macy's we bought a ton of stuff for the new house back here in the US and got the 0% interest for 12 months on their credit card for the first purchase or some-such. What the lady at the counter did was to run 2 separate transactions on the card so the second, much smaller, transaction fell outside of the "first purchase" and incurred the minimum monthly interest charge. Over the course of the 12 months, I'd have been in a slight deficit thanks to these additional charges, so I paid the damned thing off in full and threw it in the drawer.

So Macy's went from having a part-time AmEx card user to one that never uses it all because they didn't want to uphold their own promo Picking up pennies in front of a steamroller

Barbara , January 9, 2019 at 5:55 pm

Some years ago, I got such a 0% offer from a bank which issued one of my credit cards. This one was for existing debt and lasted until the debt was paid off. I was happily paying off my debt in reasonable monthly installments. After I paid my 6th monthly installment, I got a letter from the bank saying that they needed to raise the interest rate and would appreciate if I would concede. They added that if I continued to insist on 0%, as was my right to do, my credit card would be discontinued on the last payment. I chose to continue the 0% deal and, as promised (the only promise they kept), my credit card was cancelled thereafter.

Fast forward several years, I regularly get credit card offers from said company. Needless to say, I don't think much of people (or businesses – corporations are people too!) who renege on deals. You can guess what is not in my wallet!

The Rev Kev , January 9, 2019 at 4:18 am

Excuse for for asking but just to clarify a point. When you send mail to Cigna and you say that you record the details, are you talking about certified mail and registered mail then? The reason that I ask is that by using the same in Oz, it has saved both my daughter and I individually over a thousand dollars each when the recipient tried at first tried to deny receiving what we sent until confronted with tracking numbers that can be checked online.

Arthur Dent , January 9, 2019 at 9:15 am

More and more I am going to tracking numbers with signature required for things that have any sort of value.

The joy of focusing on shareholder value is that all other stakeholders are subservient to it. Ultimately, the sheer greed of the corporations is likely to force the general population to demand a government-run single-payer system where at least they can vote the politicians out of office instead of having unaccountable executives making their lives miserable. The inability to repeal the Affordable Care Act was just the first shot across the bow.

Spent more time in Canada over the past few weeks. Everybody I spoke to up there is utterly baffled by what is going on in the US and is seriously wondering if the US is officially insane. They cannot understand why we continue to live down here. BTW – many of these people are white people over 50 with military backgrounds and little to no college in the demographic that would have been probably voting for Trump in the US.

Octopii , January 9, 2019 at 1:05 pm

Have considered moving but they don't want us up there.

Yves Smith Post author , January 9, 2019 at 9:44 am

It takes $3+ per envelope to send something certified and a half hour tax on my time to go to the post office.

And sending a letter certified does not prove what was in the letter. It's useless from an evidentiary standpoint. Cigna could claim the envelope had no claims in it, or that the claims were "unscannable" (another "dog ate my homework" they've tried now and again). It's useless in proving a submission.

monday1929 , January 9, 2019 at 4:22 pm

Yves, you might try video-taping the mailing process, including video showing the papers as legible etc as they are sealed in envelope and handed over postal counter and showing tracking numbers.
Include in the envelope a letter explaining you will post video on you-tube if they claim "unscannable" or that envelope was empty.
United Healthcare broke dozens of promises to "call back"- they never ONCE did so. Hopefully not to far off topic, I would like to keep NC updated on current complaint with NY Office of Professional Discipline regarding a dentist who possibly hid about 100 bad (as in semi-criminal) Yelp reviews by establishing a phony company name and shifting reviews there. So far, after one month not a peep from Port Chester regional office where referred to.

beth , January 9, 2019 at 7:35 pm

Alert to United Healthcare Medicare Supp. retirees. I'm sure the UH did this not just to me but to all of those who carelessly pay all bills sent to them. When I signed up for AARP United Healthcare insurance, the rep told me that he would have to accept a check for the first month and then had to put me on a ckg acct withdrawal plan. I had never done that before and didn't like the idea. It turned out that that saved me in the long run for two reasons. First they billed me for the first month after accepting my check. I did not pay it and by the time I received it they had already taken money out for the second month. I am sure there are many seniors who just paid the bill anyway. Slick trick & sick trick.
And then a year later I was finally diagnosed with my genetic disease after all these years. I began getting the only medicine specifically for this disease which since it is an orphan drug is expensive. They rejected the first bill from the provider and told them I was not a member of the plan. I was thrilled that I had had the money taken out of my acct. so they could not say the check was late.

Kradek , January 11, 2019 at 12:25 am

Why won't these companies let us email the claims? Cheaper for all, content and dates verifiable

run75441 , January 9, 2019 at 11:00 pm


Green Card works in court and I have used it with Ocwen

flora , January 9, 2019 at 11:17 pm

By 'green card' do you mean the usps certified return receipt green card?

vlade , January 9, 2019 at 4:33 am

Hmm.. I haven't seen "the cheque will be issued" excuse for ages now, courtesy of pretty much all European payments being direct and settled on T+1 latest.

I guess having netflix and Facebook (the "great innovations" coming out of the US) is more important to a number of US residents than a working payments system like say the EU has.

mle detroit , January 9, 2019 at 10:12 am

I've been trying unsuccessfully to decode your first sentence. What is this payments system, where can a neophyte learn about it, does the UK use it, and what how Brexit affect it?

Kpl , January 9, 2019 at 4:36 am

When bad behaviour and fraud go unpunished this is what one should expect.

Disturbed Voter , January 9, 2019 at 5:27 am

Stick to your guns, and make them meet your business performance metrics!

Heath insurance is inherently un-profitable in the long run, unless service is denied.

oh , January 9, 2019 at 3:58 pm

Not really. Denial of claims is yet another way for them to pad their profits.

Louis Fyne , January 9, 2019 at 6:32 am

cigna bought express scripts and the deal closed in december.

it could be cost-cutting-induced incompetence. it could be intentional revenue padding. could be both.

and ya, compared to the daily/weekly neoliberal microaggressions, no wonder why after 3weeks a lot of people shrug when it comes to the government shutdown

Spring Texan , January 9, 2019 at 11:06 am

Love your phrase "neoliberal microaggressions." We need to start using that more!

Very descriptive.

rd , January 9, 2019 at 12:22 pm

This government shutdown is going to get very interesting as the Trump Administration tries to expand what are "essential services" requiring workers to come in without pay. So far it hasn't interfered with my travels because the TSA and ATC workers are all there working without pay. I believe tax refunds are going to be declared "essential" so those workers will be called back to process them without pay. This will likely be occurring in numerous other areas as the Administration gradually discovers that government workers actually do something.

Thad Allen had an interesting interview on NPR this morning as he discussed the Coast Guard working without pay:

The GOP may have finally figured out how to pay for tax cuts: you still provide the services but you don't pay the workers!

Octopii , January 9, 2019 at 1:08 pm

Reminds one of the old Soviet saying, "They pretend to pay us and we pretend to work."

ambrit , January 9, 2019 at 1:10 pm

This dynamic is beginning to resemble the joke attributed to Lenin. "The Capitalists will sell us the rope with which we hang them."
I cannot think of a better way to energize a general strike than this.

Oh , January 9, 2019 at 4:02 pm

The TSA is just a pretend act anyway. It's all for show.

Larry , January 9, 2019 at 7:01 am

Perhaps the plan is to fatigue customers over small amounts to condition them to give up appeals over larger disputes.

Homard Mard Hankee Ospetsua , January 9, 2019 at 7:05 am

For most of the year 1982, I worked as a parlegal for a workmen's comp law firm representing petitioners (the sick or injured workers). Almost all of the cases we handled were from workers whose disability checks had stopped after six weeks. Always six weeks. That's the point at which the insurer would stop sending the checks and the worker would call us. Then, someone (like me) from the law firm would call the insurer. There would be one of a a stock set of about half a dozen responses, ranging from "my desk is so messy haha, but I know I saw that check in these papers somewhere" to "we don't have the proper medical documentation" (even though of course there needed to be medical documentation for them to send the first 6 weeks' worth of checks). After one or two phone calls from us, the checks would begin to flow again in a week or two (including checks for any week that the insurer had missed).

Oh, and 95% of these cases were from workers whose first language wasn't English.

The theory of the folks who'd been at this business for awhile was that, by having a built-in delay at the six-week mark, the insurers were making a little extra interest.

cnchal , January 9, 2019 at 7:17 am

> . . . in terms of abuses, this is small beer . . .

Tens of millions of small beers ends up being a gigantic vat of beer for Davos Man running Cigna. This is the result of Davos Man purchasing laws to prevent class action suits, which was paid for by stealing small beers from the peasants for decades.

I do pity the human capital at Cigna. Their worth to Davos Man is how well they steal small beers, the more they steal the higher in the organization they go, aspiring to be the next Davos Man.

Brenda Pawloski , January 9, 2019 at 8:33 am

If you are able to send your pharmacy claims online and keep an electronic copy, you can resubmit easier, faster and more often. I have done this with Cigna. I agree it is odd how they choose to ignore random claims, but it happens enough that it seems to be intentional.

BRUCE STONE , January 9, 2019 at 8:36 am

Have you tried sending the mailed correspondence by priority mail? Like Certified Mail–you get a tracking number– and documentation of delivery–but it's half the cost and my insurer will routinely refuse to accept certified mail to the claim's PO box number.
They can't refuse to participate in the priority mail tracking systems -- and it's as good in court as certified mail–although it does lack the signature credo from return receipt.

Also–my insurer routinely loses my docs and has a similar time limit on claims–but I have successfullly re-submitted based on documenting the previous sent item and the tracking data from USPS–most such systems require them to accept a resubmit when you can prove you sent it within the timeframe .

Yves Smith Post author , January 9, 2019 at 9:47 am

See the comment above. Won't help. Only proves I sent a letter in, not what was in the letter. They can say they got the earlier letter but the claim was not in it or was unscannable.

Questa Nota , January 9, 2019 at 8:54 am

Expecting reimbursement is a pre-existing condition and is not covered by the Plan for which you have eligibility. Refer to paragraph x.xx in section q.qq of user agreement #.##.

Yves Smith Post author , January 9, 2019 at 9:48 am

Not germane. Please don't offer irrelevant comments.

Kiwi , January 9, 2019 at 10:35 am

The comment was a joke

mle detroit , January 9, 2019 at 10:17 am

Good one, QN. Hope you didn't get scorched when you poked the Dragon.

RMO , January 9, 2019 at 4:39 pm

"You've chosen the 'never pay" plan option which clearly states (in this microdot that also serves as a period at the end of paragraph 4) that no claims you make will be honored. It's a good choice if you never get sick. Oh I hate to see a grown man cry Rev So get out of my office!" (adapted from the Pythons)

beth , January 9, 2019 at 7:40 pm

Do I sense a little hostility? Maybe you can be more explicit with what you are angry about.

Medical Quack , January 9, 2019 at 9:25 am

Well I gave a speech last year to a big doctors group about a lot of this and have written about it for years, it's called the Healthcare Algo Cartel. What folks can't see and don't want to believe is that there's tons of quants (called non traditional actuaries in healthcare) modeling policies and finding new areas every day where coverage for certain items can be "scored" to reduce the amount the insurer will pay.

I just don't know how long you all want to keep living in virtual perceptions and not realize this has been going on for years, just like the stock market, algos and their query results are running everything, and folks are too busy on Facebook or screaming at a box (Alexa) to take time out and learn up. Cigna is basically emulating United Healthcare and using the same models, but they don't own a PBM like United does or they don't own a bank like United does (an industrial bank). That bank by the way holds a lot of HSA money and United a couple years ago bought all the Wells Fargo HSA accounts, that's how they grow.

Nobody mentions an exit fine either for Cigna and Express Scripts. There's 5 years left for Cigna to be required to OptumRX as a PBM, contract signed with Catamaran, which OptumRX bought. Those folks with OptumRX as their PBM with Cigna have 5 more years before a switch to Express Scripts can be facilitated unless Cigna takes out another bond sale to pay it off.

People need to learn up and see what's going on, insurers are big data people and nobody seems to get that but just hang around long enough and more will come out about United Healthcare and what they and Apple are doing together, you already have United pimping Apple watches and all Apple employees are given an Optum Bank HSA account with one scratching the others back already.

Cigna by the way has Express Scripts hitting the big coupon savings route to compete, you can search that one up. Did you know that if you use a coupon to save money on your RX that that money can't be applied against a deductible? Time to learn up folks and see what the healthcare algos are doing, they're denying your care and access and there's more MBA quants on their way to be hired at insurers to model even more ways to profit by "scoring" consumers into oblivion, it's how you don't qualify done by queries and predictive models. The more complex they make it, the more insurers profit off of consumers not understanding the game and we don't have the ability to fight back (we don't have the algos and computer code).

Kris Alman , January 9, 2019 at 12:21 pm

The Cigna-Express Scripts merger is brilliant financial engineering to further consolidate insurance companies with PBMs in the fight between them and PhRMA over price gouging.

The coupons that you can get through Good Rx is a scheme of Express Scripts.

Now that Trump has signed bills lifting pharmacist 'gag clauses' on drug prices, the pharmacist can point you in the direction of drugs cheaper than your co-pays, which you pay-out-of-pocket and can't claim toward your deductible. What a win for Cigna/ExpressScripts!

Yves, I can't believe you have been so patient with Cigna! Complain to your insurance division. Though, I will add that while this may work at the individual level, it does nothing to create systemic changes.

JerryDenim , January 9, 2019 at 12:48 pm

Sorry to be so dense, but can you elucidate a bit more on "scoring" and how health insurance companies are using your personal data they've purloined or surreptitiously obtained to deny care? If you're not self-insured but receiving subsidized insurance through an employer plan are you still affected by "scoring"?

I would never knowingly register any health monitoring device with a health insurer or employer and I've always thought those who do are foolish, but recently I was considering buying an Apple Watch solely for the express purpose of being able to surf while being on call for my job. I believe there may be other waterproof, cellular-enabled wrist devices in the consumer space now besides Apple, but they all seem to be equipped with health monitoring sensors as well. I would never voluntarily register such a device with any programs in exchange for discounts, but it seems like linking a watch/wrist-phone to my cell phone account would be an iron identity shackle. I would really like a tiny robust cell phone reciever to screen calls while I'm in the water, which has the ability to increase my quality of life, but I don't want my heart rate and vitals logged and sold. I modified a song lyric a couple of decades ago to coin my own phrase; "Never mind what you're buying, it's what you're selling" – It becomes more true each passing year.

jfleni , January 9, 2019 at 9:31 am

RE: Health Insurer Greed or Desperation? An Odd Data Point From Cigna.

The "Nitty-gritty" A Scam wrapped in a Swindle, with a Fraud right on top!
Run -do not walk – to Medicare for ALL!

jefemt , January 9, 2019 at 9:58 am

Not fun to do the work, but imagine a few million Cigna clients at $13.00 a pop. Will pay for attorneys and accountants.

As to Priority Mail/ tracking/proof, why do we tolerate such a byzantine battle-prone system? Think of the man-hours Yves and countless others spend on running down this hors*#t. If she and others (doc offices/ care providers?) billed Cigna and others at a reasonable but market-based hourly rate for the collective man-hours spent on claims, Cigna et al would be out of business.

Its a level of complexity that is completely unnecessary. Our complacency, tolerance, and acceptance is pretty astounding. Must be the very real primacy of the threat and fear that personal health prompts. Immoral to lever off of this. Care versus insurance. Insuring a mortal being. Ridiculous premis only Wall Street could concoct. And we buy it because markets, capitalism, rugged individualism, American Exceptionalism.

Doc friends and family consistently state 35-40% of their costs, staff deals with billing, coding, reimbursement. There is huge savings to be gained in the process if we would go to a single payor system.

But you all know that- preaching to the choir.

I am still trying to figure out how to tie personal health choices, like diet and exercise, moderate alcohol use, etc.. and some incentivized skin-in-the game, some 'pain' disincentivises folks from over-using single payor and insisting on the highest dollar cost latest most expensive treatments -- how can this be institutionalized?

But , no need to reinvent the wheel- countless other nation-states have figured it out. For a nation of business-persons, we appear to be, as my old dad used to say, dumberthanwhaleshit

hunkerdown , January 9, 2019 at 12:04 pm

If they're overusing the system, what's the underlying reason? Probably loneliness or neurosis, either treatable on an outpatient basis as a mental/community health matter. If they demand heroic treatments or frivolous diagnostics , what's the underlying reason? Probably the consumer model of medicine and direct-to-patient marketing of interventions, also easily treatable (through restriction of advertising) and known to work well in other nation-states. If they eat crap, what's the underlying reason? The standard American diet is a consequence of national policy to grow grain instead of vegetables, which can be changed slowly and with effort as a public health hazard. If they don't exercise, what's the underlying reason? Built environments and lifestyles that are hostile to pedestrian traffic, which is not necessarily such an easy problem to solve due to the private interests and investments in the status quo, but whose opposing public interests would grow much stronger under a single-payer system.

Yet, all of these solutions, however difficult and world-changing they might be, are more effective over the long term and less resentment-inducing than having citizens pay to be individually scourged as a service in the name of individual incentive.

Yves Smith Post author , January 9, 2019 at 3:10 pm

The overwhelming majority of people do not elect to overconsume medical care.

People who don't exercise often don't have the time or money to do so (gym membership). Do not say "Anyone can run." Running on pavement is knee replacement futures. And there are people like me who could never jog even when young.

The ones that do fall into a few categories:

1. Ones with "lifestyle" diseases, like diabetes due to overweight/poor diet and smoking-related diseases. Problem is that these are typically the result of stress. Very hard to get off cigarettes and harder if you are subject to stress/use nicotine as a performance drug. Obesity significantly due to American portion sizes. too many refined carbs, and again, stress. And once people get fat, it is very hard for them to take and keep the weight off. I have managed to do so by virtue of seriously undereating for 40 years (<1200 calories/day, and that includes when I was exercising vigorously pretty much daily). Most people can't do that for social reasons. It is hard to be a meager eater when you are eating with other people.

2. People who are already have a problem and have been marketed to to demand tests and treatments. The classic version of this is doctors prescribing antibiotics to people with flus. The patients demand a treatment and the MD does not want to get in an argument. More extreme is patients not wanting to hear that there aren't any good options for what they have and shopping for an MD who will intervene anyhow. Another is all those new pricier drugs marketed on TV "Ask your doctor about..."

beth , January 9, 2019 at 8:15 pm

The best information about obesity is still the UCSF researcher Robert Lustig. He now has his own website but it not organized well to my taste and fails to keep the best long lectures there. Actually the best information in the shortest time is his first lecture that has been seen millions of times by geeks like me is "Sugar: The Bitter Truth" a one hour and 29 minute lecture he did in 2009. Youtube cuts it up and wants me to pay for it. But each time I have seen it has been on UCTV or UCSF. For those of us who want to understand the science this one is a must. There is good videos after that, but this is the foundational scientific information.

I can't give you a link because Google and the sugar industry makes it maddingly hard to find and moves it around.

flora , January 9, 2019 at 9:46 pm

It's a very good presentation. Thanks for the reminder. From UCTV:

bob , January 9, 2019 at 3:21 pm

"I am still trying to figure out how to tie personal health choices some incentivized skin-in-the game "

You're trying to noeliberalize it. "How do we build in the need for 18 layers of very well paid bureaucrats who deal out spite, and lack of care, as part of their job descriptions?"

I can't imagine any more 'skin in the game' than all of the skin, and literally all of the person.

Do you ghouls even read what you write?

k. , January 9, 2019 at 9:59 am

As someone who managed a medical billing office in the 80s and 90s I can assure you that insurance companies losing claims is nothing new. That's why the advent of electronic billing to Medicare and Medicaid and BCBS and others was so wonderful. Finally, Medicare stopped "losing" all those claims we offices had to refile all of the time.

Sometimes it helped me to envision the office I was sending the paper claim to, imagining a constant turnover of new employees who didn't know what they were doing, or throwing away a stack of bills at the end of the day because they hadn't met their quota.

It's like borrowing "your" money longer, not paying what's owed in a contract.

EoH , January 9, 2019 at 10:38 am

Thanks for sharing.

This seems reminiscent of bank ATM fee scams. A dollar here, $2.50 there – systemwide – and soon you're talking about real money. It also matters whose budget the costs or income are shifted to, which is often a highly-competitive internal game. Same with the now ubiquitous and easily incurred penalty charges, which banks use to generate the outlandish returns they now consider their due.

Coincidentally, I was recently helping a friend with her latest medical bill. Always good sport if it's not your bill. It was "only" for about a thousand dollars. Her insurer paid the amount, minus her deductible.

The hospital system sent her a follow-up bill for the same service. It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not.

Here's the hospital's argument: It had billed the insurer and the patient only a thousand dollars. But the insurer considered bills for up to two thousand dollars for that service. Having, in effect, underbilled the insurer, the hospital added the difference between its first bill and the maximum amount the insurer would consider.

But the hospital did not bill the insurer for the higher amount, only the patient. That routine also happily avoided any reasonable and customary cap the insurer and hospital had agreed to.

The hospital does this routine systemically. Its "customer service" operators have a canned response for outraged patients: You'll pay it in the end and we'll dock your credit score in the bargain. Film at eleven.

Steven Hoel , January 9, 2019 at 10:39 am

I have found this letter (or to be used as script to be read over the phone) to be 100% effective so far. I suspect it gets kicked up to a supervisor who wants to get rid of the crazy customer:

"To: "Big Corporation"
Regarding Inv #


You have issued your fourth notice. Please note that this is now my third notice to you of whom to bill. If I must spend more time on this issue, I will be billing out at $200 per hour in ½ hour increments. Sending a further notice without contacting "XYZ Healthshare" for payment will indicate acceptance of my terms.

This blood work was for my annual Physical. I am covered under "XYZ Healthshare" and they cover one physical per year.

Please submit above referenced invoice for payment to:

"XYZ Healthshare"
Payor ID:
P.O. Box 1234
Anytown USA 12345

Insured: John Doe
Policy # 123456789

It is not acceptable to simply send me another payment notice when you are not billing as I instructed. I will send my billable hours in return and submit a copy to my attorney.

Best Regards,

John Doe"

NotTimothyGeithner , January 9, 2019 at 10:44 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.


jrs , January 9, 2019 at 12:56 pm

Of course Trump's misdeeds are becoming abuses much closer to home, having one's government closed becomes real impractical even on the day to day level.

Spring Texan , January 9, 2019 at 11:08 am

Wow, this makes me very happy I work for a self-insured employer which unfailingly pays bills in good faith. Awful.

California Bob , January 9, 2019 at 12:10 pm

I was with United Healthcare in the private sector for years, with good coverage and no serious issues (PPOs only). When I went on Medicare, I stayed with AARP-endorsed UHC; I figure the last thing UHC would want is a bunch of angry retirees with time on their hands. So far, so good.

Jimmie Q , January 9, 2019 at 5:40 pm

I don't know about that. I've not been able to login to the AARP/UHC website for 2 months.
They admit that there is a problem. After 2 months I'd say they are correct.
You'd think they would go back to the last working version of their log-in software.
What kind of testing was performed before inflicting this crap on their users. None, by the looks of it.
It's pretty obvious when you can't login. How stupid are these people ?

Oregoncharles , January 9, 2019 at 12:17 pm

Not medical, but a similar penny-ante scam that we encountered from a car rental, which I will name: it was Dollar/thrifty – they're the same company. Ironically, we were happy with their service, given the price, UNTIL we turned the car in at the Indianapolis airport. The agent claimed the system was down, so couldn't give me a receipt; foolishly, and feeling time-pressured, I walked away without one (don't do that).

The company first claimed the car had not been turned in, then discovered that it had been re-rented the next day, so charged us for an extra day. I refused to pay it, since an agent had agreed that our boarding passes from the airline proved when we'd turned it in. In fact I got the credit card company to reverse the extra amount (their service was exemplary). Attempts to clear it up on the phone led to hangups at their end, and ultimately they sent the $50 difference to collection. When I got a call, I started yelling about it being a fraudulent charge and making legal threats; never heard from them again – not worth it for such a small amount. I felt that principle was involved.

And now the oddity: Dollar/Thrifty belongs to Hertz, but we've had no trouble renting from Hertz. Go figure.

JerryDenim , January 9, 2019 at 1:21 pm

One scam I've seen Hertz attempt on me twice, was claiming a car wasn't returned completely full, like 1/16th shy of full, then they proceed to charge you for a full tank of gas (15, 20 gallons or whatever that means based on the vehicle) at some outrageous price like $9.00 a gallon. It's a scam that is always going to add up to over a hundred dollars. It's a quick, vicious one-time burn (sharp practice as Yves would say) they try to pull on customers they figure may never rent from them again anyway. Algos I'm sure. Always document, document, document with rental cars. Cell phone cameras are great in this regard. Photos of the odometer with gas gauge displayed work great for refuting such charges.

beth , January 9, 2019 at 8:32 pm

I was definitely scammed by Dollar/Thrifty. I have switched to using Enterprise but they sometimes don't have an airport location. So far so good. I usually take only one trip a year.

Oregoncharles , January 9, 2019 at 12:21 pm

Afterthought: Insurance is a service business, which would normally depend on providing reasonably good service – granted, in this case Yves is locked into an old contract, so they might be trying to get rid of her.

I wonder if this sort of behavior means they see the political handwriting on the wall, figure the business can't last much longer, and are trying to extract the last dime, because it IS the last?

EoH , January 9, 2019 at 3:13 pm

Standard business model. Nothing special.

I question whether insurance is any longer a service, at least for the customer. Health insurance used to be a business that offered a reasonable service, service tracking and payment processing for employers, who purchased the service for their employees as a form of deferred compensation, in exchange for a reasonable fee.

The model seems to have changed to one of open and notorious self-dealing. The intermediary has become a principal, and no fee and no level of profit is too great. The intermediary makes decisions that look to the lay person like practicing medicine – not seemingly in the interest of savings its employer customers money, but it making it for themselves. The model is a major reason for the extraordinary cost of medical care in the US.

Synoia , January 9, 2019 at 12:26 pm

Small claims court?

ambrit , January 9, 2019 at 12:57 pm

That would be a tax on her time, she has to physically show up in court for the 'trial', and money, as in, filing fees. A small claims judgement does not guarantee payment. That could take a second suit. (I had to go for a second filing to get my judgement paid.)
This is a systemic problem. The remedy in that elusive "perfect world" is to change the system.

AdamK , January 9, 2019 at 12:55 pm

"Corporate America has been institutionalizing penny-ante scams "

Don't get me started. 24 hour fitness sold membership for super sport facilities at a higher price promoting the deal that gives free towels to members while at the gym. 3 years after, towels are gone. Price was raised several times, and there is no difference between regular facility and super sport. No one complained. They simply got the news and adjusted. Saying something is not considered appropriate, so we continue to pay more and more and getting less and less.

ambrit , January 9, 2019 at 1:05 pm

Same dynamic used for Internet services, telecom services and cable services. Life is legally an "ethics free zone" today.
Reminds me of one of the more vulgar posters I once saw. A mid range shot of a woman's "private parts" with a 'tattoo' above the mons pubis saying; "Abandon all hope, ye who enter or exit here."

WheresOurTeddy , January 9, 2019 at 2:32 pm

seems germane:

"The political crisis we are facing is simple. American commerce, law, finance, and politics is organized around cheating people." – Matt Stoller

JerryDenim , January 9, 2019 at 1:10 pm

This story is strangely similar to the battles I used to wage years ago with Sallie Mae to pay down my student loan principal ahead of schedule. I would send checks that would never be cashed. If they ever were the amount would always be applied to interest and never principal. Tons of emails, phone calls and letters stretching out over months all about one check or another.

"Oh you sent the check to that address? No that's all wrong, try this one." "Oh, no, you have to write a letter stating you want the amount to be applied to principal. Oh, you did already? Oh, well send one to this department at this address instead and your next one should be be applied to principal."

Absent an aggressive regulator corporations can play infuriating games like this for years until the consumer gives up or lawyers up. Lawyering up is no guarantee of victory and doesn't make financial sense for small penny-ante grievances. Most people stuck dealing with hassles like these don't have the money to lawyer up anyway and corporations know it. I remember back in 1995 when my phone service was changed without my permission and I received an outrageous bill. I placed one phone call to the FCC that lasted a few minutes and I received a $250 credit and my phone service was free for the next year. I miss those days.

"The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home."

Absolutely. It's really tough for working class Americans to shed a tear for Central American border jumpers having a rough go of things with ICE when their own government refuses to protect them from thousands of small capitalist depredations that they are subjected to on a daily basis.

tongorad , January 9, 2019 at 1:11 pm

Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me
I received an errant charge when I chose to cancel my account with a phone-carrier giant. Lots of time on the phone speaking to different people, demanding to be sent an invoice/bill.
In the end, I just paid. I was losing sleep over it.
I have a feeling that these kinds of extractions are commonplace.
What a world

beth , January 9, 2019 at 8:41 pm

If we are discussing scams, I had an earthlink account for about a year when I noticed that rather than billing me monthly, they were billing me every 20 days and when I noticed it, they said they would refund my money at my request.

And what do you think happened?

M Morrissey , January 9, 2019 at 1:20 pm

File a complaint with your state insurance department. Most departments have dedicated staff who will follow up on such issues. If you one of many victims, it can lead to a "Targeted Market Conduct Examination" of the company.

Once that happens, the insurer will readily settle claims such as yours because besides fines, the impact of an examination damages their reputation. Also, if there is a pattern of misconduct, the complaint information is shared between the 50 states, who may also initiate targeted examinations. Don't get mad–get even.

monday1929 , January 9, 2019 at 6:06 pm

You are kidding, right?
And ."damage their reputation"- thank you, I needed a laugh.

JBird4049 , January 9, 2019 at 1:37 pm

The more people are in need of medical care the less likely they are to have the time, energy, or even money to maintain their records, read all their letters and emails, and write and call enough times to finally get their money. The sicker are the less likely you will get paid. Truly vulture capitalism.

Dan , January 9, 2019 at 1:57 pm

I tend to agree that these 'billing mistakes' are a conscious strategy on the part of insurers. For several years Kaiser (Northern California) would attempt to bill me $15 every time for routine physical visits (which my physician had requested!). Routine physicals, of course, are meant to be free under the ACA. Every time the receptionist would request payment in advance, I would decline an tell them that the appointment should be free. They then would proceed to bill me by mail, and I had to spend time calling them to resolve the issue. Unlike Yves' experience with Cigna, Kaiser customer service was always friendly and promptly resolved the 'error'.

Since we changed from a Covered California plan to a small business plan this practice appears to have stopped, at least for me. Nonetheless, this annual ritual was a ridiculous tax on my time, and I wonder how many people who were less informed/hostile to their insurer than I am have just paid these false and illegal fees up front. The consistency of this practice over a period of years makes it hard for me to believe that there is really error involved, as opposed to a subtle fraud by the insurer.

monday1929 , January 9, 2019 at 6:13 pm

It is never an "error", and it is always in their favor (proof it is not an error).
They target the sickest, least likely to fight back. There is an MBA somewhere who wrote an algorithm designed to screw the old and sick. My nightmare with United "healthcare" (why are they allowed to call themselves or imply they are healthcare providers?) was on behalf of someone else who never could have fought these scammers.

tiebie66 , January 9, 2019 at 3:31 pm

So, they legislate to permit disruption against you and not against them, but year after year – figuratively speaking – you send the same people back there. The system is beyond reform, is that not clear by now? Vote for anyone –except– a Democrat or Republican. It would create upheaval at first, like spring cleaning, but it is as necessary. If you are too timid to make changes, you will only get weaker and weaker until you are too weak to resist. Don your yellow jackets!

But on a different level – where does this originate? My sense is that it is a failure of education. The nation can neither read, nor write, nor think. This makes for easy victims. Do teachers really deserve better pay? Is teaching not a 'calling' rather than a career? Should teachers not do better? But perhaps the failure of education is also, in part, institutionalized?

Big Tap , January 9, 2019 at 4:55 pm

Speaking of insurance scams some involve a PPO type policy. More and more often I'm told at the time of service of a doctors visit to pay up front. With a PPO policy you usually don't know exactly what you owe till after the insurance company tells you what your co-pay is and then you're billed. When you pay up front bring overcharged intentially is the scam. Getting a refund of your own money can time consuming.

Pft , January 9, 2019 at 6:49 pm

Not only health insurance. Good luck if your house burns down and you want them to honor the contract in a timely fashion. They hold off until you accept less hoping you hate living in 2nd rate accomodations enough to cave. My sisters contract called for full replacement of all contents regardless of age. She paid a hefty premium for that. They held out for months offering less saying some of the contents were older and not worth the replacement cost which is what she wanted to avoid by paying the extra premium for the upgrade. Came to an agreement somewhere between but took 15 months before she could move back in.

EoH , January 9, 2019 at 7:37 pm

There is the basic problem that with almost every medical service, the customer does not know the price until the bill(s) show up in the mail. (Nor have they any training or experience that would enable them to choose alternative treatments or vendors.) Only later still does an insured customer find out what portion of that bill is her responsibility. And that's without errors and intentional mis-billing, which are common.

The usual conservative refrain that patients need more skin in the game studiously ignores that patients always have all their skin in the game, even though no one tells them the game or the rules until it's too late. It is an environment that could only make predatory behavior flourish.

Katherine , January 9, 2019 at 9:57 pm

This is one of the most unsettling posts I have read on NC since becoming hooked about 6 months ago.

cat sick , January 10, 2019 at 2:44 am

Live a healthy lifestyle and self insure

I am sure not dealing with insurance companies is a sure way to lower stress levels and therefore require much less healthcare.

As a fairly healthy 50 year old I find that even though I have access to a good free first world healthcare system (Singapore ), never using it and paying doctors direct for all my needs is the way to go and probably costs me 10% of what a US citizen might pay for an insurance policy.

When I am in the US and so many people you meet have "meds" that they take on a daily basis it leads me to believe that not only are the insurance companies in on the scam but also the doctors and drug companies plying people with drugs that in most cases probably make them worse off

The first $20 of care I would reccomend is to buy one copy each of "how not to die" and "the case against sugar" read these and then do all you can to avoid both insurance companies and doctors .

[Jan 09, 2019] $3.5 Trillion A Year- Is America's Health Care System The World's Largest Money-Making Scam- -

Jan 09, 2019 |

Authored by Michael Snyder via The Economic Collapse blog,

If the U.S. health care system was a country, it would have the fifth largest GDP on the entire planet. At this point only the United States, China, Japan and Germany have a GDP that is larger than the 3.5 trillion dollar U.S. health care market. If that sounds obscene to you, that is because it is obscene. We should want people to be attracted to the health care industry because they truly want to help people that are suffering, but instead the primary reason why people are drawn to the health care industry these days is because of the giant mountains of money that are being made. Like so many other things in our society, the health care industry is all about the pursuit of the almighty dollar, and that is just wrong.


me title=

In order to keep this giant money machine rolling, the health care industry has to do an enormous amount of marketing. If you can believe it, a study that was just published found that at least 30 billion dollars a year is spent on such marketing.

Hoping to earn its share of the $3.5 trillion health care market, the medical industry is pouring more money than ever into advertising its products -- from high-priced prescriptions to do-it-yourself genetic tests and unapproved stem cell treatments.

Spending on health care marketing nearly doubled from 1997 to 2016, soaring to at least $30 billion a year , according to a study published Tuesday in JAMA.

This marketing takes many different forms, but perhaps the most obnoxious are the television ads that are endlessly hawking various pharmaceutical drugs. If you watch much television, you certainly can't miss them. They always show vibrant, smiling, healthy people participating in various outdoor activities on bright, sunny days, and the inference is that if you want to be like those people you should take their drugs. And the phrase "ask your doctor" is usually near the end of every ad

The biggest increase in medical marketing over the past 20 years was in "direct-to-consumer" advertising, including the TV commercials that exhort viewers to "ask your doctor" about a particular drug. Spending on such ads jumped from $2.1 billion in 1997 to nearly $10 billion in 2016 , according to the study.

As a result of all those ads, millions of Americans rush out to their doctors to ask about drugs that they do not need for diseases that they do not have.

And on January 1st, dozens of pharmaceutical manufacturers hit Americans with another annual round of massive price increases.

But everyone will just keep taking those drugs, because that is what the doctors are telling them to do. But what most people never find out is that the pharmaceutical industry goes to great lengths to get those doctors to do what they want. According to NBC News , the big drug companies are constantly "showering them with free food, drinks and speaking fees, as well as paying for them to travel to conferences".

It is a legal form of bribery, and it works.

When you go to most doctors, they will only have two solutions to whatever problem you have – drugs or surgery.

And since nobody really likes to get cut open, and since drugs are usually the far less expensive choice, they are usually the preferred option.

Of course if doctors get off the path and start trying to get cute by proposing alternative solutions, they can get in big trouble really fast

Today's medical doctors are not allowed to give nutritional advice, or the American Medical Association will come shut them down , and even if they were, they don't know the right things to say, because they weren't educated that way in medical college. So instead, M.D.s just sling experimental, addictive drugs at symptoms of deeper rooted sicknesses, along with immune-system-destroying antibiotics and carcinogenic vaccines.

That's why any medicine that wrecks your health is easy to come by, just like junk food in vending machines. The money isn't made off the "vending" products, the money is made off the sick fools who are repeat offenders and keep going back to the well for more poison – it's called chronic sick care or symptom management. Fact: Prescription drugs are the fourth leading cause of death in America, even when "taken as directed."

Switching gears, let's talk about hospitals for a moment.

When you go to the hospital, it is often during a great time of need. If you are gravely ill or if an accident has happened and you think you might die, you aren't thinking about how much your medical care is going to cost. At that moment you just want help, and that is a perfect opportunity for predators to take advantage of you.

Trending Articles "A Soft Coup Against Donald Trump Is Underway" Declares

Turkey is going on the attack against John Bolton following his weekend antics in the Middle East, which most recently

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me title=

Just consider the example of 24-year-old Nina Dang. She broke her arm while riding her bicycle in San Francisco, and so she went to the emergency room.

The hospital that Facebook CEO Mark Zuckerberg donated so much money to definitely fixed her arm, but later they broke her bank account when they hit her with a $24,000 bill

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50 . Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay , which the hospital threatened to send to collections in mid-December.

Most Americans assume that if they have "good health insurance" that they are covered if something major happens.

But as Dang found out, you can still be hit with crippling hospital bills even if you have insurance.

Today, medical debt is the number one reason why Americans declare bankruptcy. Because of the way our system is set up, most families are just one major illness away from financial ruin.

And this kind of thing is not just happening in California. The median charge for a visit to the emergency room nationally is well over a thousand dollars , and you can be billed up to 30 dollars for a single pill of aspirin during a hospital stay.

Our health care system is deeply broken, and it has been designed to squeeze as much money out of all of us as it possibly can.

Unfortunately, we are stuck with this system for now. The health care industry is certainly not going to reform itself, and the gridlock in Washington is going to make a political solution impossible for the foreseeable future.

the_river_fish , 3 minutes ago link

Healthcare has displaced Retail as the largest employer in the United States

Consuelo , 9 minutes ago link

The ghost of Ted Kennedy that keeps on giving...

He played an outsized role in the trashing of the doctor/patient relationship.

css1971 , 10 minutes ago link

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered "in-network." Zuckerberg San Francisco General has not done that bargaining with private plans, making them "out-of-network." That leaves many insured patients footing big bills.


Constrain supply. Increase the price.

That was the purpose of the 1973 HMO act. It was at this point, that US medical costs began to escalate far beyond the rest of the world.

LawsofPhysics , 10 minutes ago link

Considering the demographics of the country and the fact that fraud is the status quo now, this should not surprise anyone.

LawsofPhysics , 21 minutes ago link

That's a tough question considering we don't really know how much is flowing to the military industrial complex. My guess healthcare spending is in second place.

[Jan 08, 2019] Risk On Again - Distractions from the Real Problems and Issues

Jan 08, 2019 |

Stocks and Precious Metals Charts - Risk On Again - Distractions from the Real Problems and Issues

"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December..."

Sarah Kliff, A $20,243 bike crash: Zuckerberg hospital's aggressive tactics leave patients with big bills

"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."

Elizabeth Warren

Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be free to do just about whatever they wish in billing consumers.

Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common sense, with Big Pharma running a close second. But the Banks are not all that far behind.

I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being swept along because they have little practical recourse or power. To speak up is to be punished, and severely.

A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will be done at the Medicare rate and not at some ficitonal billing statement.

I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never informed beforehand.

The real solution is of course universal healthcare, which has been implemented for years by every major developed nation but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.

Stocks managed to extend their rally today despite some setbacks.

We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare, finance, insurance, or pharmaceuticals.

Have a pleasant evening.


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