Proletarian Doctors Redux

Bethune led the way. And Canada quietly has produced a model for creating doctors faster than the monopoly guild that is the College of Physicians and Surgeons would like to admit to.

As I have pointed out here before the way to create more doctors and reform the medicare system is to break the haughty power of the monopoly the doctors guild has on its profession. And it appears that such a possibility has been in place for forty years but nobody bothered to admit it existed.

Add to this a program of nurse practitioners, free tuition and a commitment to work in rural areas, as well as community based health clinics with doctors on salary we would well be on our way to ending the health care crisis. And it would cost far less than any other reform.

Canada could produce a lot more doctors at a lower cost, and medical students would save thousands in tuition if most of its medical schools moved to a three-year program, the Canadian Medical Association Journal suggests.

Such three-year programs have existed for decades at McMaster University in Hamilton, Ont., and at the University of Calgary.

Dr. Paul Hébert, editor-in-chief of the Canadian Medical Association Journal and a professor of medicine at the University of Ottawa, wants to know how they measure up against the four-year programs at the rest of the country's medical schools.

"We've had a 40-year experiment go on, and no one's looked at that data as far as I know in a very cogent and detailed manner," he told CBC Radio's Ottawa Morning Friday, the same week he published an editorial titled "Is it time for another medical curriculum revolution?" in the bi-weekly journal.

Dr. Norman Bethune, assisted by Henning Sorensen, performing a transfusion during the Spanish Civil War

Norman Bethune (1890-1939) was a Canadian thoracic surgeon. During the 1930s he became a convinced communist, and this led him to Spain, where he joined the anti-Fascist struggle. On the Spanish battle fields he became aware that 75% of serious battle casualties would survive if operated on immediately. In early 1938, he arrived in China, and proceeded to Yan'an, the revolutionary base area of the Chinese Communist Party. Mao Zedong commissioned him to organize a mobile operating unit in the interior of North China. Although he was forced to work under extreme circumstances, sometimes operating for forty hours straight without sleep, and within minutes of the front lines, he saved the lives of many Chinese party members and soldiers. He died of septicemia, contracted when he cut himself while operating under great pressure from advancing Japanese forces.

Norman Bethune (1890-1939)

• born in Gravenhurst, Ontario
• served as a stretcher bearer in a field ambulance unit of the Canadian army in France in 1915
• a bout of tuberculosis inspired his interest in thoracic surgery
• joined the surgical team at Montreal's Royal Victoria Hospital
• produced over a dozen new surgical instruments
• became disillusioned with medical practice because often patients who were saved by surgery became sick again when they returned to squalid living conditions
• visited the Soviet Union, and secretly joined the communist party in 1935
• opened a health clinic for the unemployed
• promoted reform of the health care system
• fought the fascists in Spain in 1936
• in Madrid he organized the first mobile blood-transfusion unit
• in 1938 he went to aid the Chinese against the Japanese invasion
• in China he formed the first mobile medical unit, which could be carried on two mules
• died of an infection due to the lack of penicillin, the infection ocurred during surgery due to a lack of surgical gloves
• Bethune is regarded as a martyr in China and is referred to as "Pai-ch'iu-en" which means "white weeks grace"
• next to his tomb in China there is a statue, a pavillion, a museum, and a hospital dedicated to him
• the family home in Gravenhurst is now a museum
• played by Donald Sutherland in the biographical film: "Bethune: Making of a Hero"
• biography: The Scalpel, The Sword by Ted Allen and Sydney Gordon
• for more information see Canada firsts (1992) by Ralph Nader, Nadia Milleron, and Duff Conacher

History of the Norman Bethune Tapestry by William C. Gibson, MD, DPhil

One day when I had just arrived back in Vancouver from World Health Organization meetings in Geneva I dropped in to see H.R. MacMillan at his home. As usual he began: "What is the best thing you saw while away?" I told him of a very fine tapestry which was in a travelling exhibition, showing Norman Bethune in the Chinese countryside. "Find it," he said. After months of correspondence with Chinese and Geneva sources, I had to report failure. So H.R. said: "Get one made in China and send me the bill." So I sent off to Shanghai a colour photo to be reproduced, giving the approximate size which we could accommodate. Six months later the Bethune tapestry arrived, almost buried in mothballs! We placed it in the Sherrington Room, where many came to study it.* The setting depicts a former Buddhist temple, which Bethune had converted to his operating room for the Eighth Route Army in Hopei Province in the north. Bethune had sailed on a CPR Empress liner from Vancouver soon after Japan attacked China, because he was at that time in Salmon Arm, B.C. on a fundraising mission for his blood transfusion service in the Spanish Civil War. On hearing of the invasion of China, he gave up his efforts for Spain, where he had done yeoman service for the legal government of Spain despite the Department of External Affairs in Ottawa, which threw no end of roadblocks in his way. With a Canadian nurse he set off for China, accompanied, alas, by an American Red Cross surgeon who turned out to be a chronic alcoholic (as I believe he had been in Newfoundland). In 18 months Bethune became a legend. After his death at age 49 of an infected finger, cut while operating, Mao wrote a eulogy which was memorized by every schoolchild in China. When I first visited China in 1973, with the Bethune Foundation, every stop we made was highlighted by children reciting it. * One visitor was Dr. Wong, who was Bethune's anesthetist, shown in the tapestry. Bethune is doing a rib resection to get at a lung damaged by a bullet. You can see him bending over the wedged-open chest of the soldier.

SEE:

Proletarian Doctors

Socialized Medicine Began In Alberta

Ex Pat Attacks Medicare

Privatizing Health Care

Laundry Workers Fight Privatization

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Norman Bethune, privatization, Canada, CMA, Doctors, businessmen, privatizing healthcare, health care, public health care, medicare, private health care
medicare, health care, Canada, physician assistant , nurse practicioners, doctors on salry, privatized-health care, private-medical-services, medicine, privatization,community health clinics,

Why Cable News Hates Medicare for All
BY LUKE SAVAGE  
JACOBIN

02.06.2021

From last year’s Democratic primaries to this year’s Biden agenda, TV news coverage of the health care debate is outrageously skewed against single-payer reform. To understand why, we need look no further than their business model

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Bernie Sanders speaks while Elizabeth Warren and Pete Buttigieg listen during the Democratic presidential debate at the Fox Theatre on July 30, 2019 in Detroit, Michigan. (Justin Sullivan / Getty Images)

If you watched any number of last year’s Democratic primary debates, there’s a good chance you noticed one of their most overt and recurring patterns: namely, a near total hostility toward the idea of a universal, single-payer health care system.

At times, this hostility could be almost baroque, with one voice or another invariably shouting it from the TV screen any time the subject of health care was broached. This extended not only to most of the candidates themselves (Bernie Sanders being the sole contender to unequivocally champion Medicare for All) but also to the panelists and commentators featured on the cable networks that hosted the debates. As Sanders himself pointed out during a Detroit event hosted by CNN, even the ad breaks generally offered no solace to those hoping for even a momentary cessation of the barrage: health insurance and pharmaceutical companies seizing every opportunity to bombard viewers with misleading industry agitprop about the breathtaking wonders of profit-driven health care.

On its face, the existence of this advertising effort likely surprised no one. Wherever their politics happen to sit, and whether they sympathize or not, most Americans probably grasp the idea of an industry using ad space to protect its business model. Even the hostility toward Medicare for All then expressed (and still expressed) by many Democratic politicians has a fairly straightforward explanation: a whopping majority of voters, after all, favor campaign finance reform and believe donations from corporations and special interests have a direct influence on the decisions those running for office make. It requires no great leap of the imagination to understand that politicians raising funds from figures in the very industry threatened by a particular policy aren’t going to be its most vocal champions.

This is what arguably makes the hostility directed toward Medicare for All by figures at the cable networks themselves the most insidious of all. Consider the following question, posed to Sanders during the Detroit debate by CNN’s Jake Tapper:


Let’s start the debate with the number-one issue for Democratic voters, health care. And Senator Sanders, let’s start with you. You support Medicare for All, which would eventually take private health insurance away for more than 150 million Americans in exchange for government-sponsored health care for everyone.

Despite his attempt at a somewhat balanced framing, and whether he realized it or not, Tapper was essentially regurgitating a talking point seeded by the insurance industry and its lobbyists (just take it from former Cigna-executive-turned-whistleblower Wendell Potter). Regardless, a question from a journalist tends to carry a lot more weight than a TV ad or even a spiel from a warm-and-fuzzy-sounding liberal politician.

We can’t know, obviously, how Tapper genuinely feels about the issue or even what role he played in writing the question. Given the near total uniformity of hostility to Medicare for All expressed on large cable networks, it’s far less relevant than the disjuncture between the perspectives they tend to showcase and majority public opinion — which consistently favors the creation of a universal, single-payer model.

The existence of media bubbles, of course, is one obvious explanation: exorbitantly well-paid and often politically insular communities of pundits and cable hosts inhabiting a completely different socioeconomic reality and being far better served by the current health care system than most Americans. To really understand why cable networks were so hostile toward Medicare for All throughout the Democratic primaries (and why they almost certainly will be for the foreseeable future), however, we have to ultimately look at their business model. Consider the following point made by Institute for New Economic Thinking executive director Rob Johnson during a recent interview when asked about Medicare for All:


Public opinion polls show more than 70 percent of the population is in favor of Medicare for All. It’s not the population that doesn’t want it, and they’re the ultimate voters. It’s vested interests and the struggle that has to do with the relationship between money-raising campaign war chests and the probability of re-election and what you might call the refractory influence of the mainstream media, where pharmaceutical companies in particular and insurance companies as well are very big advertisers. [emphasis added]

Concise though it is, Johnson’s remark is fairly close to a comprehensive explanation of why Medicare for All remains so marginal throughout the political class, despite the overwhelming popular support it boasts. What he calls the “refractory influence” of the mainstream media is arguably the most crucial factor involved: given the dependence of large networks on health insurance and pharma companies for advertising revenue, it’s really no wonder the astroturfed effort to discredit socialized medicine enjoys something approaching full-spectrum dominance on cable TV. As Noam Chomsky and Edward S. Herman wrote in their famous study Manufacturing Consent: “The power of advertisers over television programming stems from the simple fact that they buy and pay for programs — they are the ‘patrons’ who provide the media subsidy.”

CNN’s Detroit debate is a case in point; the network was demanding at least $300,000 from companies advertising, with a single thirty-second spot costing an estimated $110,000 — and groups like the so-called Partnership for America’s Health Care Future (in practice, a front for various corporate interests), filled out many of the slots. Regardless of how anchors or hosts think about an issue like health care, the networks’ basic model essentially precludes meaningful critique of the status quo by design. As long as it persists, don’t expect to see the public interest or popular opinion reflected anywhere on cable TV.

Klein My Way Healthcare Reform

It is known in Alberta as the 'Third Way, for medicare reform. But in reality it should be called Ralph Kleins My Way or the Highway medicare reform.

I am not the only one concerned about the Klein Government announcement this week that he will challenge the Canada Health Act with his long awaited Third Way reforms that will supposedly be introduced into the next sitting of the Legislature in February.

This will be six years after the passage of Bill 11 which opened the door to private health care in Alberta. A bill which saw mass spontaneous demonstrations at the Legislature, some of the largest ever, attempts to take over the Leg.

Despite all that and a continued fight against the privatization of health care, and despite numerous costly studies by the Klein government on how to privatize, studies which continued to show it was a DUMB idea, ah well now Ralph can push ahead with little or no opposition from Ottawa. Or so he thinks.

Blogging Tory CIVITANTENSIS says its Deja Vu all over again, and wonders why the PC caucus unanimously approved it. Well probably they didn't, since Ralph has lied before about caucus unaniminity. CIVITANTENSIS also wonders why Ralph is challenging Stephen Harper over this.

Well thats simple; in Alberta it doesn't matter the government in power in Ottawa, they are all 'Eastern Bastards' to good old Klein. Opps except Harper is from Calgary. Good point that. Now we will see who is loyal to Harper and the Conservatives and who is loyal to King Ralph and his Party of Calgary.

Calvert fears Klein's reforms

"I have never quite understood the specifics of what the Third Way is,'' Calvert said. "If the Third Way finds itself to be in violation of the Canada Health Act -- the principles and values expressed in the Canada Health Act -- then I oppose any violation of that Act, its principles and its values, anywhere in Canada.''

The Alberta premier was also quoted as saying he believes the Canada Health Act, designed to help the federal government ensure the province and territories adhere to the principles of a free and universal publicly funded health system, should be amended in the future.

Klein said he and Prime Minister-designate Stephen Harper "are on the same wavelength'' and the federal leader promised during a brief conversation with Klein on Thursday to respect areas of provincial jurisdiction.

Calvert stressed the role of the federal government is to ensure the Canada Health Act's principles and values are being adhered so that Canadians can be confident health care will be provided no matter where they live or what is available in their wallet.

"That is the role of a national government and I would look to Mr. Harper's government to maintain that role,'' he said.

Also see:

Klein Dares Harper

Beware the Boogey Man

Two Tier Alberta

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Study details U.S. health spending by region

Peer-Reviewed Publication

YALE UNIVERSITY

Contact: Bess Connolly, 203-432-1324 or elizabeth.connolly@yale.edu

For Immediate Release: July 20, 2022

Study details U.S. health spending by region

New Haven, Conn. — A new study by researchers at Yale, Stanford, and Dartmouth provides the first nationwide, small-area analysis of the variation in spending by the three main funders of health care in the United States: Medicare, Medicaid, and private insurers. The researchers’ goal: to see whether there are regions that have low health spending by each of the three payers simultaneously or whether distinct factors drive health spending variation among the payers.

The study, published July 20 in JAMA Network Open, analyzes spending data for more than 100 million individuals and shows that while health spending per payer varies significantly across regions, there are almost no regions that have simultaneously low spending by Medicare, Medicaid, and private insurers or that have universally high spending across all three payers. In fact, the researchers found that distinct factors appear to be driving regional variation in health spending across each payer segment of the U.S. health system.

The finding has significant public policy implications because it suggests that policymakers should focus on payer-specific interventions that target individual sources of waste rather than searching for silver-bullet interventions, according to the researchers.

“In the past, policymakers have identified particular regions as having efficient health systems based solely on care delivered through Medicare,” said study co-author Zack Cooper, an associate professor of health policy at the Yale School of Public Health and of economics in the Faculty of Arts and Sciences. “By analyzing data from all three dominant payers, we show that analysts cannot understand the overall performance of regions by studying only one payer or learn about a model for the country by studying one region.

“Our findings suggest that payer-specific factors drive health spending across and within regions, suggesting that policymakers should focus on payer-specific strategies to increase efficiency in the U.S. health care sector.”

Olivia Stiegman, a pre-doctoral fellow for Yale’s Department of Economics and Tobin Center for Economic Policy, and Chima D. Ndumele, an associate professor of public health at the Yale School of Public Health, are co-authors of the study. The other co-authors are Becky Staiger of the School of Medicine of Stanford University and Jonathan Skinner of Dartmouth College.

The United States spends about $3.8 trillion annually on health care. By most accounts, its health care sector is inefficient compared to those of other developed countries. Medicare, Medicaid, and private insurers covered 14.2%, 19.8%, and 49.6% of the country’s population in 2019, respectively.

The study found that only three regions nationwide were simultaneously in the lowest fifth of spending across the three payers: Boulder, Colorado; Bloomington, Illinois; and Olympia, Washington. Only four regions were in the highest fifth of spending simultaneously for the payers: the Bronx, New York; Manhattan, New York; White Plains, New York; and Dallas, Texas. What a region spent on the privately insured had a low correlation (21%) with what was spent in the region on Medicaid recipients and a 2% correlation with what was spent on Medicare recipients, the study found. There was also only a 16% correlation between what a region spent on the Medicaid program and what was spent on the Medicare program.

“What this tells me is that, in essence, we have multiple different health systems in the U.S. — the Medicare program, the Medicaid program, and private insurers,” said Cooper. “This means that we are going to need payer-specific policies if we really want to move the needle on increasing the productivity of health care. We have a complex health system; this means we’re going to need nuanced policy to be effective[DK1] .”

The study showed that the Medicaid and privately insured populations exhibited more variation in spending across regions than did the Medicare population. This reflects the fact that prices for care paid for by private insurers and Medicaid are generally market-driven and vary substantially across regions, while the federally administered Medicare program relies on regulated payments to health care providers, the researchers suggested.

Notably, there was substantial correlation in the regional utilization of health care services across payers, according to the study.

“While spending may not be strongly correlated across the payers, the utilization of care is,” said Jonathan Skinner, a research professor at Dartmouth College. “This finding demonstrates that health care services such as hospital days are determined at the regional level both by the underlying health needs of the population and by supply factors such as hospital beds and the supply of physicians.”

The researchers also concluded that the factors causing the variation in spending are specific to each main payer. For private insurance, regions with high prices tend to have high spending. For Medicare, regions with higher spending have more specialist physicians per capita. For Medicaid, regions with higher spending have more hospital beds and births per capita, the researchers explained.

In February 2021, Cooper launched the 1% Steps for Health Care Reform Project jointly with Fiona Scott Morton, the Theodore Nierenberg Professor of Economics at the Yale School of Management. The project convened dozens of leading scholars and identified 16 targeted interventions — policies like increasing organ donation, raising antitrust enforcement budgets, and decreasing home health fraud — each supported by a robust evidence base, which, if implemented collectively, would lower U.S. health spending by nearly 10%.

“These are the types of policies that will reduce health spending,” said Cooper. “Nobody writes country music songs about incrementalism, but I think it’s really going to be a long path of small steps that’s going to make our health system more efficient.”

---

JOURNAL

JAMA Network Open

DOI

10.1001/jamanetworkopen.2022.22138 

ARTICLE TITLE

Geographical Variation in Health Spending Across the US Among Privately Insured Individuals and Enrollees in Medicaid and Medicare

Third Way MIA

King Ralphs mauch touted 'Third Way' in Medicare reform is still MIA. It wasn't in his TV Inofmercial the other night and yesterday it was absent, MIA in fact, from the Throne Speech.

“This session, government will take steps to improve access, sustainability, choice, innovation and efficiency in Alberta’s health-care system,” said the speech.Despite its references to offering choice and innovation in health care, it provided no details of Klein’s proposed “third way,” which could open the door to private health insurers and for-profit hospitals offering services now covered by medicare.

Guess after all this time, all those focus groups, all the studies, all the reviews, after Bill 11 , after King Ralphs Grand Tour touting his reforms, this new bill has yet to be written!

Klein conceded yesterday the legislation has yet to be drafted, but he still hopes to push ahead after some form of consultation with Albertans."Hopefully it will be done this spring, but I am waiting to see what the legislation will look like."

You would think these guys would have it prepared. But of course not. In Alberta everyone knows the real legislation is done in cabinet, by decree. Where the government doesn't have to face the discomfort of democarcy and Question Period. And of course mass disapproval and the disapproval of the masses.

What is the Third Way?

February 23: Vigil in Support of Public Medicare 12:15 pm Front steps of the Alberta Legislature building Vigils on the steps of the Leg will be every Monday evening at 7:15 pm and Wednesday afternoon at 12:15 pm while the Legislature is in session.

Copyright © 2006 Friends of Medicare.

This is what the rest of Canada is going to have to get used to soon, with the Harperites now in power in Ottawa, Alberta.

Here is the Alberta version of Accountable Government.

When answering a question on health care from New Democratic Party Leader Brian Mason, Klein said he’s been inundated with requests for more money from Alberta’s regional health authorities.
How much money are they asking for? Well....
KLEIN: “Without going through the whole list, the total is $100.6 billion — $100.6 billion this year alone — and they (New Democrats) have no solution other than to spend, spend, and spend more.”
$100.6 billion? That’s 10 times the size of the entire health budget!
Klein repeated the $100.6 billion figure five more times — a figure he puzzlingly used to browbeat and berate the New Democrats, as if they want to spend $100 billion more on health care.
Oops — he later dropped the figure to $10.6 billion.
Double oops — after Question Period he dropped the figure yet again to $1.6 billion.
Klein said he made a mistake. He did the math himself on what the health authorities are requesting and came up with the wrong number — twice.

Wow that sounds just like an anwser those guys in Ottawa that just got turfed used to give in QP.. Will Klein Share Chretiens Fate?






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U$A

We Don’t Just Need Medicare for All — We Need a National Health System

The founders of Physicians for a National Health Program put single-payer health care on the map. Now, discussing the next phase of the movement, they say even single-payer won’t be enough to fix the problems caused by continued privatization.

By Steffie Woolhandler, David Himmelstein 

May 3, 2023

Source: Jacobin


Physicians for a National Health Program (PNHP) emerged thirty-five years ago amid the austerity cuts of the Reagan administration, which threatened to hollow out critical social safety-net programs like Medicaid. Rather than marshaling physician support to defend the limited (albeit lifesaving) poverty program, PNHP opted instead to pour its energies into expanding the possibilities of what health care reform could look like in the United States. From its inception, PNHP has committed itself to securing universal, comprehensive single-payer national health insurance. Under a single-payer system, all residents of the United States would be covered for all medically necessary services paid for by progressive taxation.

Since the turn of the twentieth century, both US political parties have faithfully accommodated private interests in their proposed health policy reforms. When doctors David Himmelstein and Steffie Woolhandler cofounded PNHP in the 1980s, support for single-payer health care was largely restricted to the radical left and a handful of progressive policy analysts. The doctors’ belief in health care as a public good emerged from their left-wing commitments and their personal experiences having witnessed the unnecessary suffering of patients in the current system. Later, as researchers, they published groundbreaking studies exposing private insurers’ administrative bloat, waste of resources, and widespread denial of care, revealing a health system in desperate need of transformation.

Writing in the Annals of Internal Medicine in 1988, Woolhandler and Himmelstein offered an explicitly Marxist understanding of the political economy that drives American medicine, a system of extraction that generates profit at the expense of patient health and physician autonomy. The authors envisioned an alternative health care system in the United States that would meet the needs of people, not corporations. “A reorientation of policy will require an alternative coalition of forces capable of resisting the imperatives of pecuniary interests,” wrote Wooldhandler and Himmelstein. “Physicians together with other health care workers and our patients may provide such a force.”

Unfortunately, the diagnosis is now even more dire than it was when PNHP was founded. The bad actors are no longer limited to private health insurers; American medicine is inundated by a powerful assortment of private interests from Big Pharma, giant hospital corporations, and private equity firms. Even retail giants like Walgreens, CVS, and Walmart are in on the grift. The private takeover of American medicine imperils the financial and physical health of millions of Americans. Suffice it to say that the prescription offered by PNHP’s physician-researchers remains as necessary today as it was thirty-five years ago.

For physicians and medical students fed up with the status quo, PNHP and its student wing SNaHP represent vital counterpoints to organizations allied with private interests such as the American Medical Association. PNHP today claims twenty-five thousand members representing all fifty states, with local chapters throughout the country. Data analysis by Himmelstein, Woolhander, and other researchers empowers PNHP members to make an evidence-based case for transformative health reform to their patients and their physician colleagues. Working alongside other single-payer standard-bearers like National Nurses United and Democratic Socialists of America, PNHP helped make single-payer, more popularly known as Medicare for All, a household concept. A 2020 Pew survey found that more Americans favor a single-payer system than any other option.

For Jacobin, Jonathan Michels sat down with Woolhandler and Himmelstein to commemorate PNHP’s thirty-fifth anniversary. They discussed PNHP’s inception, how the organization helped propel national health insurance back into the political debate, and the ways single-payer advocates must adapt for the next phase of the movement.

JONATHAN MICHELS

You cofounded PNHP during the rise of neoliberalism in the 1980s. Why did you choose to focus your energy on securing national health insurance at a time when single-payer health care was not really on the table?It was obvious that the financing of the health care system was interfering with the actual practice of medicine.

STEFFIE WOOLHANDLER

I was close to the end of my training as a doctor, and it was obvious that the financing of the health care system was interfering with the actual practice of medicine. The financing system was one of the things that was preventing my patients from getting the care they needed, and preventing me from delivering the quality of care I wanted to deliver. So that was really what motivated me.

DAVID U. HIMMELSTEIN

The Reagan administration was assaulting the care of particularly poor people, and encouraging corporate growth. A number of us who were activists had spent some energy trying to oppose savage Medicaid cuts, and concluded that Medicaid and the targeted programs for the poor were indefensible. They were the worst health care programs of any developed nation, and we couldn’t fight Reagan by defending a lousy program that only helped part of the population. A broad cross section of people in the country were in deep trouble, and strengthening Medicaid would do little for them. At that point we had a number of people, particularly in the Boston area, turn to advocacy for much more radical reforms.

We were working in Boston with a group called the Gray Panthers, a radical elders’ group that a woman named Maggie Kuhn from Philadelphia had founded some years before. In the 1960s and 1970s there had been disagreement between those who advocated for a national health service, where the government would own all of the health facilities and employ the health workers directly, and those who advocated for national health insurance, where the government would take over only the insurance. We wanted to avoid that fight, so we chose a different term: national health program.

JONATHAN MICHELS

What was the impetus for the creation of PNHP?

DAVID U. HIMMELSTEIN

The triggering event was that the Gray Panthers and the groups we were working with were putting on the Massachusetts ballot a referendum instructing (in a nonbinding fashion) their congressional representatives to vote for national health insurance. We were afraid that the Massachusetts Medical Society would come out in opposition to that ballot initiative, and we thought we needed to rally more physician support for national health insurance. In June of 1986, there was a conference of clinicians caring for the poor at a left-wing conference center in New Hampshire. We went to that conference with a plan to propose the formation of a group of physicians for a national health program.We couldn’t fight Reagan by defending a lousy program that only helped part of the population.

JONATHAN MICHELS

Did any individuals or organizations provide a template for PNHP? I see obvious parallels between PNHP and groups like the Medical Committee for Human Rights, whose advocacy work eventually included making demands for universal health care.

DAVID U. HIMMELSTEIN

Well, Steffie and I were both the progeny of the radical left of our generation. I had gone to my first two years of college in Montreal, partly out of fear that I might need to stay there because of the draft, and was actively involved in the radical left and Montreal anti–Vietnam War work. Steffie actually dropped out of college to organize outside a military base in Killeen, Texas. So we were very much on the Left from our mid- and late-teen years on. The Medical Committee for Human Rights was largely fading by the time I was in medical school, so it didn’t have directly a big influence on me, although I knew a number of people who had been active in that and remained active on the Left in medical circles.

I think we were more influenced by the women who were the remains of the Black Panther Party in Oakland, who had formed a group called the Coalition to Fight Infant Mortality. When we were interns and residents at the public hospital in Oakland, we collaborated with them in efforts to improve the maternity services and prenatal care available to the black community. One lesson from that was understanding that systematic research could be a useful piece of advocacy work. One of our earliest research projects was documenting a large number of people refused care at private hospitals in the Oakland-Berkeley-Alameda County area, who were then sent to the public hospital emergency room often in grave condition. That was more formative for us than what really were the remains of the previous generation of the Left in health care.

JONATHAN MICHELS

Why did you decide to focus specifically on mobilizing physicians rather than forming a broader coalition of health care workers?

DAVID U. HIMMELSTEIN

We went with a physician group not just because we saw the need for it, but because we were convinced that the possible reach into the physician community would be much greater if there were a physician group. It was initially formed and the stationery was printed up as Physicians for a National Health Program, a component of the Network of Health Professionals for a National Health Program, and we actually had “NHP squared” stationary printed up.

Our hope was that other health professionals would have their own groups that would form part of a broader coalition. There were some nurses, including some from that conference, who tried to put together Nurses for a National Health Program and social workers who tried to put together Social Workers for National Health Program, but they never really flew.

JONATHAN MICHELS

How did the physician community react to the creation of PNHP?

STEFFIE WOOLHANDLER

The fact that we were able to garner so many members speaks to other physicians feeling something similar. There were a lot of physicians who wanted to focus on how we could change the financing and delivery so that the doctors could actually do their jobs and the patients could get the care they needed. That really helped crystalize some of the feelings that people had — that they were being blocked from doing their job.

JONATHAN MICHELS

Can you describe the process of drafting and publishing the first physicians’ proposal for a national health program, and how that elevated PNHP’s status in the media and within the medical community?

DAVID U. HIMMELSTEIN

Having a concrete proposal published in the New England Journal of Medicine lent tremendous gravitas to the organization and made it very much mainstream in the physician community. In the meantime, we had developed templates for talks that people could give, which were recognizably similar to the kinds of talks that doctors were used to hearing but took a different tack politically. They had slides presenting data quantitatively and making the case in very systematic, evidence-based ways that doctors were comfortable with.They had slides presenting data quantitatively and making the case in very systematic, evidence-based ways that doctors were comfortable with.

We’d been reaching out to colleagues in a small way, but the New England Journal article really put the organization on the map in a very different way, and also put us on the map in the public media. We were invited onto the major news shows of the time. There were two other proposals published for health reform around the same time, and we were often on with those folks. We were very happy when people started characterizing our view as one representing the doctors and assigning us that role.

JONATHAN MICHELS

How did you end up working with Representative John Conyers to craft HR 676, which was introduced into Congress in 2003?

DAVID U. HIMMELSTEIN

After the New England Journal of Medicine article, we subsequently thought we needed a second bite of the apple. We published further proposals in various journals for elements of a national health program: a quality improvement proposal that was published in the Journal of the American Medical Association (JAMA) that Dr Gordy Schiff led the development of, and a proposal for reform of long-term care that Charlene Harrington, a nursing professor and nurse herself at University of California at San Francisco, led the development of.

After that, we thought we needed to restate the original case, because it had been a while since the New England Journal piece. The JAMA had a call for papers about health reform, and we drafted a slightly revised version, particularly addressing the alternative proposals for reform that were circulating at about that time, which was early in the Clinton administration. It was that proposal that Conyers actually picked up as the basis for his plan.

In the interim, in 1990 Steffie had gotten a fellowship financed by the Robert Wood Johnson Foundation. It had a policy fellowship where mid-career health professionals were assigned to some branch of government for a year in Washington as health-policy advisors. Much to the consternation of the people who ran the fellowship for the Robert Wood Johnson Foundation, she decided to take her assignment with Bernie Sanders, who was then a first-term congressman from Vermont, and Paul Wellstone, who was a newly elected senator from Minnesota.

Meanwhile I had been in touch with Conyers’s office, and was supposed to work with his committee on the fiscal impact of single-payer reform. At the last minute, they decided that my continuing role as a leader of PNHP was probably not compatible with working for the committee. So I instead got a part-time job working with Ralph Nader’s and Sidney Wolfe’s Public Citizen’s Health Research Group, and spent that year in Washington, really working in Congress as an advocate for single-payer health care. I got to know the Conyers people not as a staff person, but as an outside lobbyist.

So Steffie and I had fairly close connections in Congress. And when the JAMA piece was published, Congressman Conyers reached out and said we should put in a bill of that. So basically, the bill was drafted almost verbatim from the JAMA piece.

JONATHAN MICHELS

History shows us that it is often corporate Democrats, not Republicans, who impede efforts to secure single-payer health care, whether it is through outright opposition or watered-down reforms like the Affordable Care Act (ACA) that entrench private health insurance.

In a little-known yet important act of civil disobedience, several PNHP members, including doctors Margaret Flowers and Carol Paris, were arrested in 2009 protesting Democratic senator Max Baucus’s refusal to allow single-payer advocates to take part in a committee hearing on health reform.

Reflecting on the subsequent passage of the ACA over the objections of PNHP members, how do you process the betrayal of the single-payer movement by mainstream Democrats?

DAVID U. HIMMELSTEIN

Well, we were very disappointed by the ACA. It was a terrible plan. Better than nothing, but you know, it basically adopted Nixon’s proposal from 1971, which was offered as a counter to Ted Kennedy’s national health insurance plan and had been taken up by the right wing and the Republicans in Congress. We had hoped for much better, obviously.

When Dr Ron Sable died from HIV, Dr Quentin Young, who was a mainstay of the medical left in Chicago when he was still practicing, took over as PNHP’s national coordinator from Ron. One of Quentin’s patients was Barack Obama. Quentin was extremely hopeful about who he referred to on a first-name basis as Barack.

The rest of us were maybe more realistic about it. We were pretty sure that the Democrats wouldn’t, at that point, countenance radical reform. I mean, we’d seen it with the Clintons. Bill Clinton was the first Democratic candidate to abandon national health insurance as part of his platform. Quentin had actually led a sit-in outside the Democratic National Convention that nominated Clinton, protesting the pulling of national health insurance from the platform. So we were pretty realistic about how the mainstream of the Democratic Party would behave.We were pretty sure that the Democrats wouldn’t, at that point, countenance radical reform.

JONATHAN MICHELS

You coauthored a 2022 editorial published in the Nation arguing that Medicare for All is not enough to ameliorate the damage inflicted by the upsurge in hospital consolidations, the incursion of private equity in physician practices, and the steady privatization of critical public programs like traditional Medicare.

Instead, you write, “A transition to public, community-based ownership — a reform model generally labeled National Health Service (NHS), in contrast to [National Health Insurance] — seems the most appropriate solution.” Can you explain what has changed over the last thirty-five years to prompt this shift in your perspective?

STEFFIE WOOLHANDLER

There’s two countervailing things going on. One is that giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP. So when we started, we were mostly up against the insurance industry and pharmaceutical industry. But now there’s all sorts of involvement by banks and for-profit ownership of health providers, so that makes things harder.

The other thing is that the health care system continues to be so dysfunctional. People with or without insurance face massive medical bills, the complete inability to afford lifesaving treatments like insulin and sometimes cancer treatments. The growing dissatisfaction among doctors is now often called burnout or sometimes moral injury. Whatever you call it, physicians recognize that the system’s not functioning very well. So the system’s own problems and dysfunctions continually create an interest in and constituency for fundamental health reform.Giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP.

DAVID U. HIMMELSTEIN

We need to have a deep understanding of what the problems in the current system are, and the shifts in the organization of the current system need to guide both our program and our political work. So I think we need to update what the vision of single-payer health care is from when we first conceived of it.

We thought we could control the health care system by replacing insurance companies with a single public financing system. And I think that was true as long as health care was essentially carried out by small-scale practices, mostly individual hospitals, that were not parts of large chains, not controlled by giant corporations. But at this point, we have the vertical and horizontal integration of ownership of the health care system. So for instance UnitedHealthcare employs seventy thousand doctors. Just taking away the insurance business isn’t going to be an adequate reform of the health care system.

We need to reconsider our reforms to think about how we seize ownership of health care assets from the corporations that have come to dominate them, and how patients and people doing health care work can really take ownership of this system. I don’t think it’s possible any more by just taking control of insurance. I don’t see a lot of advocacy for radical reform of the health care system, and that I think is the next phase that either PNHP or some new form will need to take up.

JONATHAN MICHELS

What lessons can you share with your experiences of being at the forefront of the movement for national health insurance throughout the last several decades?

DAVID U. HIMMELSTEIN

One is that the Democrats are generally much better when they’re in opposition than when they’re in power. We need to build a power base outside the Democratic Party that’s able to push it. We can’t possibly rely on it to be our main standard-bearer. The party reflects popular opinion; it doesn’t lead it.

A second is that we need to have a program that is going to improve the situation for the vast majority of the population, not just the poor. We can’t actually be in a position of defending the existing health care program. I’ve always been uncomfortable with the term “Medicare for All” because I think Medicare is a very problematic program. It doesn’t cover much of the care that the elderly and disabled actually need, and it has adopted really defective payment mechanisms. It pays hospitals in ways that encourage profit-making and all kinds of bad behaviors. So I think we shouldn’t be in a position of defending elements of the existing health care system, even those that have some positive aspects. Certainly Medicare has positive aspects, but we need to really have a new vision of what the health care system can be.We need to build a power base outside the Democratic Party that’s able to push it. We can’t possibly rely on it to be our main standard-bearer.

JONATHAN MICHELS

As we honor the thirty-fifth anniversary of PNHP and look toward the future, what mark has the organization made on the movement to secure transformative health reform?

STEFFIE WOOLHANDLER

PNHP has often helped push sort of incremental improvements, but more important even than those, it helped prevent the health care system from getting worse. Certainly, the folks who are making money off of the health care system would prefer to ignore poor people, ignore sick people, continue marketing and getting as high prices as possible. PNHP has been a voice within the physician community that has slowed that down and has opposed that push. We’ve kept saying, “We can do better. We need a fully public system, a system that is not oriented around profit, but oriented around population health needs.” We’ve kept that idea out there.

The Trump Administration Wants To Cut Back A Billion-Dollar Healthcare Program. Hospitals Say Now Is A Really Bad Time.

The Trump administration has been fighting in court with public and nonprofit hospitals since 2017 over a plan to slash the reimbursement rates for drugs prescribed to Medicare patients.

REMEMBER WHEN AUSTERITY WAS THE NEWEST THING OF THE NEO-LIBERALS, ITS NOW THEIR OLD THING IN FACT ITS THEIR ONLY THING TO SOLVE ALL PROBLEMS  

Zoe TillmanBuzzFeed News Reporter
Reporting From Washington, DC Posted on May 27, 2020

Win Mcnamee / Getty Images
President Donald Trump makes remarks during an event on protecting seniors with diabetes in the Rose Garden, May 26.

WASHINGTON — In 2018, Park Ridge Health, a not-for-profit healthcare network in western North Carolina that serves a large population of lower-income patients, delayed plans to buy a new CT scanner for stroke patients.

The Trump administration had drastically scaled back a federal drug reimbursement program that benefitted public and not-for-profit hospitals. Park Ridge, now called AdventHealth Hendersonville, stood to lose $3.3 million per year, the hospital’s chief financial officer wrote in a court affidavit, and it wasn’t just the CT scanner on the line — that money went toward a variety of services for elderly and poor patients, including new cancer treatment facilities, women’s healthcare, and partnerships with nonprofits on issues like prescription drug abuse.

Park Ridge and other hospitals have been battling with the administration in court for three years over a plan to slash by nearly 30% the reimbursement rate that hospitals get for certain drugs prescribed to Medicare patients. The hospitals won the first round. The US Court of Appeals for the DC Circuit heard arguments in November and has yet to rule, and for now the cut is still in effect. In the meantime, the Centers for Medicare & Medicaid Services (CMS) is exploring another way to make the cut if they lose the case, over the objection of hospitals.

The litigation predates the coronavirus pandemic, but the stakes are higher as hospitals nationwide lose tens of billions of dollars weekly while nonessential services and elective surgeries are on hold because of the ongoing crisis.


“If [hospitals] lost that money now, it would make an already dire financial situation worse,” Lindsay Wiley, director of the Health Law and Policy Program at American University Washington College of Law, wrote in an email to BuzzFeed News.

Hospitals that serve a high proportion of lower-income patients can buy outpatient drugs at a discounted price through what’s known as the 340B program. Until 2017, these hospitals were reimbursed by the federal government for drugs prescribed to Medicare patients at a higher rate than the discounted price the hospitals paid.

The CMS announced in 2017 that it was slashing the reimbursement rate from 6% above the average price of the drugs to 22.5% below the average cost. The agency said the program gave hospitals an incentive to overprescribe drugs and cost patients more money, and shouldn’t provide a windfall to subsidize other services.

Hospitals that opposed the change argued that they had put money earned through the program — which can run in the millions of dollars for a hospital each year — into services for poor and underserved communities, as Congress intended.

The CMS estimated that cutting the reimbursement rate for the drugs would reduce the amount of money paid to hospitals by $1.6 billion in 2018 alone. Scaling back that funding would actually increase the rates paid by the government for other services for Medicare patients — the payment system has to be “budget neutral” — but Park Ridge and other hospitals that took the administration to court said they still expected net losses of millions of dollars.

Many hospitals that participate in the 340B program “are in the red to begin with,” said Maureen Testoni, president and CEO of 340B Health, a membership group for hospitals and health systems that participate.


“So on top of that, you add this pandemic and all the financial turmoil that this has caused,” Testoni said. The pandemic has highlighted “how critical [hospitals] are ... and what an important role they play. And, financially, they’re not in a situation where they can play that role when they have this big financial reduction.”

While waiting for the DC Circuit to rule, the CMS is exploring ways to move forward with the rate cut even if it loses. Last month, the agency launched a survey to collect data from 340B hospitals that the CMS says would address the issues that led the lower court judge to rule against the government. Hospitals opposed the survey and asked the agency to at least delay it, saying they’d have to divert resources that are already stretched thin during the pandemic to respond.

"Now is not the time to distract hospitals’ attention from the vital job at hand to complete a CMS survey on drug acquisition costs."


“Now is not the time to distract hospitals’ attention from the vital job at hand to complete a CMS survey on drug acquisition costs. By launching the survey with no notice on April 24 and providing less than three weeks to respond, CMS is creating an unnecessary burden on hospitals at the worst possible moment,” Testoni wrote in a May 4 letter to the agency. The agency didn’t respond.


Representatives of hospitals involved in the lawsuits declined interview requests, citing the pending litigation. The American Hospital Association, a lead plaintiff, declined an interview request but sent a statement:

“The COVID-19 pandemic has created the greatest financial crisis in history for America’s hospitals and health systems, with our field losing over $50 billion each month. While it is too soon to have precise data on the full impact of this pandemic, the unlawful Medicare cuts that we are contesting in federal court have added significantly to the financial pressure all hospitals face,” the group said.

A spokesperson for the Department of Health and Human Services did not return a request for comment. In court, the Justice Department has argued that the district court judge lacked authority to review the rate cut at all, and that even if he could, the government had the power to bring the rate in line with what the available data showed hospitals were paying for the drugs.

“[O]vercompensation for some drugs or treatments means reduced payments for other drugs and treatments, and correcting overcompensation permits more equitable distribution of limited funds,” Justice Department lawyers argued in the government’s brief to the DC Circuit. “The result of bringing the Medicare payment amount for 340B drugs into alignment with average acquisition cost was therefore the redistribution of the anticipated $1.6 billion in savings, resulting in a 3.2% increase in the Medicare payment rates for non-drug items and services.”

Congress created the 340B program in 1992. Healthcare providers eligible for the program can buy outpatient drugs at discounted rates from pharmaceutical companies. When hospitals prescribe those drugs to patients covered by Medicare — the federal insurance program for people who are over the age of 65 or have disabilities — they submit claims to the government for reimbursement.

Starting in 2006, Congress gave the CMS two options to set the drug reimbursement rate. It could rely on what hospitals were actually paying to buy drugs if it had “statistically sound survey data” or, if that wasn’t available, the average sales price of the drugs. If the agency used the second, alternative option, Congress set a default rate: the average sales price plus 6%.

In the summer of 2017, the Trump administration announced a plan to change the rate. Under the new rule, the Medicare agency said it would pay the average sales price of drugs minus 22.5%. That rate would come closer to matching the discounted rate hospitals were paying through the 340B program, the agency said.

Hospitals don’t have to track or disclose how they use money saved through the program. Kelly Cleary, who spent three years as the chief legal officer for the CMS, said hospitals had provided examples of how they were using the funds to expand services into underserved areas and provide free or low-cost care.

“The money was going toward a purpose that was consistent with their mission,” said Cleary, who was involved in the CMS’s effort to change the rate and defend it in court. She returned to private practice last month as a partner at the law firm Akin Gump Strauss Hauer & Feld.

The chief financial officer for the Henry Ford Health System, which serves patients in Detroit and Jackson, Michigan, wrote in a court affidavit that even if the cut meant that reimbursement rates increased for other Medicare services, the hospital network still expected to lose around $8.5 million by the end of 2018 — money that had gone toward services for patients with low incomes, such as free and low-cost medications, a free community clinic, and mobile health units.

The margin between what the Henry Ford Health System paid for drugs through the 340B program and what it received back from Medicare helped hospitals in that network provide care for “underserved and indigent populations … that would otherwise be financially unsustainable,” the officer wrote.

In support of the rate cut, the CMS pointed to a 2015 report by the Government Accountability Office that showed hospitals participating in the program had an incentive to prescribe more drugs than hospitals that weren’t in the program, and that meant higher copayments for Medicare patients who were prescribed more drugs or higher-priced drugs. The agency concluded hospitals were receiving too much of a net financial benefit.

“While we recognize the intent of the 340B Program,” the agency wrote in a November 2017 notice in the Federal Register, “we believe it is inappropriate for Medicare to subsidize other activities.”

It’s a position that aligned the government with the pharmaceutical industry, which argued that some hospitals had abused the program. Drugmakers pointed out that even with a cut to the reimbursement rate, the healthcare providers would still get the benefit of discounted drugs. A representative of PhRMA, a membership group for the pharmaceutical industry, declined an interview request, but sent BuzzFeed News a copy of comments the group submitted in support of the cut.

“PhRMA is concerned that the 340B program continues to grow rapidly and without patient benefits, thus increasingly departing from its purpose and statutory boundaries,” the group wrote. “This growth in the 340B program creates market-distorting incentives that affect consumer prices for medicines, shift care to more expensive hospital settings, and accelerate provider market consolidation.”

Hospitals that supported the program, meanwhile, said the proposal punished providers who work with vulnerable patients, and they urged the CMS to focus its efforts instead on bringing down drug costs.

The agency disputed that the plan was punitive and said that “lowering the price of pharmaceuticals is a top priority” but was outside the scope of what it was considering at the time.

Hospitals and hospital associations began suing the administration shortly after the rule became final in November 2017. They argued that the CMS had come up with the new rate using a process that Congress hadn’t approved. The agency admitted that it didn’t have the “statistically sound” survey data on what hospitals were actually paying for the drugs — the first method Congress had laid out — so instead it used an estimate of average purchase costs compiled by the Medicare Payment Advisory Commission, an agency that advises Congress.

The problem with the government’s approach, the hospitals argued, was that Congress had said the CMS could either use survey data on purchase costs or the average sales price of the drugs, but not a hybrid of the two. Congress had given the CMS authority to “adjust” rates, but cutting the reimbursement rate by nearly 30% was more than just an adjustment, the hospitals said.

US District Judge Rudolph Contreras in Washington, DC, sided with the hospitals. In a December 2018 opinion, he wrote that the rate cut’s “magnitude and its wide applicability inexorably lead to the conclusion” that the agency had “fundamentally altered” what Congress had spelled out.

The judge stopped short of blocking the rule and ordering the government to reimburse hospitals for the difference between the previous rate and the CMS’s new, lower rate, however, writing that it was “likely to be highly disruptive.” He noted that the payment system had to stay budget neutral, which meant the money would need to come from another source, a “quagmire that may be impossible to navigate” given how much money the government paid out of Medicare each year. He asked for more briefing on what the agency should do to fix the problem, but that issue was put on hold as the administration took the case to the DC Circuit.

A three-judge DC Circuit panel heard arguments on Nov. 8 and has yet to release a decision. In the meantime, hospitals have continued to file lawsuits as their claims for reimbursement at the previous, higher rate are rejected; earlier this month, a hospital system in Jacksonville, Florida, which is part of the University of Florida, filed a new suit in federal court in Washington. And the CMS is going ahead with its survey over the objections from hospitals.

“The pandemic amplifies the significance of this policy, but the fact remains that there were winners and losers with the policy and it’s always going to be a zero-sum game,” Cleary said. “If the court rules against the agency and the agency is forced to walk back the policy, that stands to negatively impact thousands of hospitals.”

Wiley, of American University, told BuzzFeed News that even before the pandemic, the fight over the 340B program highlighted how hospitals and drugmakers were “actively throwing each other under the bus” in the broader debate about who was to blame for the high cost of prescription drugs and what the federal government should do about it.

“Which stakeholders voters perceive to be the heroes of the pandemic response could affect health reform and reimbursement politics for years to come,” she wrote.

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Zoe Tillman is a senior legal reporter with BuzzFeed News and is based in Washington, DC.