Kleptocapitalism

January 30, 2023 -- In today's JAMA, Salve Lucrum: The Existential Threat of Greed in US Health Care, the venerable, conservative AMA complains of the cruel economics (they actually call it a kleptocracy) of America's health care system.

The author is Don Berwick, former Administrator of the Centers for Medicare and Medicaid Services under Obama. He knows of what he writes.

The American Medical Association (AMA, for which JAMA is its prestigious journal) represents the MDeities so no fingers are pointed at docs, but big pharma, insurance companies, and hospital chains get withering scrutiny.

As well they should.

The worst culprit is "profiteering" from Medicare's Medicare Advantage (MA) program, an optional extension that enrollees can buy to increase their coverage. (For the record, for myself I buy a Medicare Supplement plan, a superior alternative to MA.) Berwick writes:

Originally intended to give Medicare beneficiaries the choice of access to well-managed care at lower cost, MA has mushroomed into a massive program, now about to cover more than 50% of all Medicare beneficiaries and costing far more per beneficiary than traditional Medicare ever has. By gaming Medicare risk codes and the ways in which comparative "benchmarks" are set for expected costs, MA plans have become by far the most profitable branches of large insurance companies. According to some health services research, MA will cost Medicare over $600 billion more in the next 8 years than would have been the case if the same enrollees had remained in traditional Medicare. Opinions differ about whether MA enrollees experience better care and outcomes than those in traditional Medicare, but the weight of evidence is that they do not.

Most bankruptcies are due to medical expense. Many forgo care due to cost. 100 million people bear medical debts. The majority of all debt collections in the US are for medical bills. As I have decried, the economics of health care in my country is shameful, grotesquely unjust, outrageous.

Let's start here: regulate what I term NoPINOs -- non-profits in name only (you saw it here first!) -- such as Kaiser whose CEO Bernard Tyson was paid $35M in 2019. Especially excoriated in Berwick's article is Oak Street Health whose CEO was paid an eye-popping $568M this year.

These NoPINOs get tax advantages in return for providing services to broader populations. This enables them to create "kleptocapitalist" grotesque wealth for those at the top of their hierarchies. Call them non-profits? As the humorist said, there ought to be a law! But it's not funny.

Is regulatory legislation likely? In a word, no. Berwick:

The cycle is vicious: unchecked greed concentrates wealth, wealth concentrates political power, and political power blocks constraints on greed... Health care leaders and professionals should lobby Congress to pass legislation to rein in greed. Reforming patent laws, changing coding and billing rules, strengthening antitrust enforcement, expanding price transparency, and accelerating global budgets for the care of populations are agendas that have languished without strong action in Congress for years because the money of incumbents drowns out the greater public interest.

But this is a fight we must fight.