key: cord-0060248-6ncx18qp authors: Salmon, J. Warren; Thompson, Stephen L. title: Conclusion: Progressive Directions date: 2020-12-16 journal: The Corporatization of American Health Care DOI: 10.1007/978-3-030-60667-1_7 sha: b168e2a0c2a16a36818a0ad08dbb47a55fa69fb1 doc_id: 60248 cord_uid: 6ncx18qp Many cultural and economic forces stand against a collective sense of popular health, partly due to the episodic piecemeal reimbursement for medical practitioners but more to focusing on high-margin activities, e.g., elective procedures and surgeries. Biomedicine’s grip remains doctor-centered, symptomatic- and disease-focused, episodic, and hospital-based with its technology fetish. Preventive medicine never took hold, and health promotion for populations never was developed. Marketplace medicine has achieved such a strong ideological grip on our national consciousness, especially within the ranks of the health professions. Vested interests have been very persuasive in their propaganda against systems in other nations. Public policy has never truly addressed the issue of what should be the nature of the relationship between health services within a profit-based economy: What is the proper role for profit-oriented firms in the supply, provider functions, and insurance segment? How should their roles be assessed and at what costs and control are they permitted? What safeguards should be instituted to preserve a more appropriate and popularly desired balance? What is the necessary regulatory oversight for maintaining accountability? More importantly, is the structure and control over what we have now the best and the only way to organize healthcare services for the benefit of the American people and for their health promotion and well-being in the whole population? Do we want a system designed and run by those with huge financial interests in the system? changes in our own healthcare system, there is little examination of other nations that may suggest new ideas, programmatic approaches, and/or even mistakes to enlighten our national public policy formulation. This would be so crucial as implementations result in significant stumbling blocks, as clearly seen in Obamacare with plan cancellations in the Fall of 2013. Republicans have also misread the strong public concerns against narrower networks and for pre-existing conditions being held sacrosanct. The obvious rebuke to Republicans as the Party of no ideas on health (just repeal but no replace) was the 2018 election where the House flipped to the Democrats and voters in four states favored expansion of their Medicaid programs under the ACA (Armour, 2018) . Marketplace medicine has achieved such a strong ideological grip on our national consciousness, especially within the ranks of the health professions. Vested interests have been very persuasive in their propaganda against systems in other nations. Canada's universal national health insurance model is maligned continually as unworkable here in the United States, even though our own Medicare system borrowed both its name and some structure from the Canadian national system-just without becoming universal for everyone! Americans do not realize how much of their money is wasted in this corporate healthcare system on overly priced, tax-supported care, coupled with such climbing out-ofpocket personal payments for their families for this corporate healthcare system. Especially compared to other nations, the United States is spending twice per capita than the universal plans in Canada and Germany with the next highest national outlays. Only lately have Democratic presidential candidates Bernie Sanders and Elizabeth Warren brought to light the huge profits in the insurance and pharmaceutical industries (Martin, 2019) , when advocating a Medicare-for-All solution to deal with them. Given the near death of the Trump "repeal and replace," Medicaid expansion referendums in 2016 indicated public favor in states where Republican governors and legislatures had turned down the ACA generous support (Mulvihill & Alonso-Zaldivar, 2018) . For too long, many citizens have faced dire financial stress over their health care. Private insurance has indentured workers to depend upon jobs they may not like; they may lose family coverage if they leave a job or as ongoing reality reveals lose health coverage with the huge unemployment. Before the ongoing massive unemployment and loss of insurance caused by the COVID-19 Pandemic, some polls seemed to indicate many people were satisfied with their private coverage, a reality surely not guaranteed now in 2020. Hospitals sue patients for unpaid medical bills and garnish their wages; unpaid bills even before became the single greatest cause of bankruptcies for American families. The American Hospital Association takes no official position on this issue, but instead funneled millions of dollars worth of ads opposing single-payer insurance. The American Medical Association dropped out of the Partnership for America's Health Care Future, begun by the pharmaceutical industry and the for-profit hospital group (Diamond & Cancryn, 2019) . Nevertheless, forces for corporatization that prefer the status quo of marketplace medicine continue to resist progressive thinking and any changes except that which benefits them. To regain a moral compass in health policy, there needs to be much greater clarity over, and charity for, the plight of the uninsured and medically underserved; health professionals witness the unnecessary suffering of these minions who have lacked access over decades; without access, they do not get better, but just suffer needlessly and then cost much more to treat downstream for their chronic illnesses when they usually end up in the public sector. Surely, the high death rate of minorities from COVID-19 has revealed the long-standing inequities embedded in our health system structure (Dean, 2020) ; their health status emanates from underlying social conditions (Case & Deaton, 2020) . Historically, the US Surgeon General's reports have annually delineated populations and disease conditions that, in a socially just and humane society, should have been significantly targeted to reduce the widespread health inequities in this richest nation of the world. Richardson (2017) has argued that Democrats must seize a historic opportunity not to make the rich richer. Yet Democrats must dislodge Mitch McConnell's Senate grip in service to Donald Trump so legislation can be passed (Editorial: Burns & Martin, 2017) . Completely absent of any compassion, the Trump Administration considers compassion in health as a sorrowfully nonexistent commodity. In the COVID-19 outbreak, testing was restrained and not widely available to the high-risk groups of elderly, prisoners, or detainees, though a few states and counties later targeted minority communities and began to address, though tragically late, nursing homes. Supply chain arrangements over essential testing supplies, personal protective equipment (PPE), ventilators, etc. were poorly coordinated and corrupt (McSwane, 2020) . Witness his May 2020 trip to Michigan extolling his made-up "man of the year award" while never mentioning the folks harmed by two power dam breaks that flooded many Michiganders' homes and businesses a few days right before (Karni, 2020) . Nor has Trump himself sadly shown much knowledge of the plight of minorities, immigrants, protestors, or anyone criticizing him. His attacks on opponents have been said to disgrace the Office of the Presidency and proven to embarrass our nation on the world stage. Thus, despite campaign promises on expanded health coverage, lower drug prices, and almost all healthcare reform ideas, there has been nothing! (Hamblin, 2019) . The "repeal and replace" cry lessened most emphasis in health care, even as Title X funding was cut from Planned Parenthood amidst Trump's remaking of women's health policy (Alonzo-Zaldivar & Crary, 2018; Luthi, 2018) . The GOP healthcare bill in 2017 sliced the Centers for Disease Control and Prevention's budget (Facher, 2017) , as well as closed down the White House's National Security Council Directorate for Global Health Security and Biodefense (Cameron, 2020), two ominous actions that left the nation less prepared for the COVID-19 pandemic. How terrible present health and economic conditions became for the working and middle class was displayed in Trump's incompetent handling of the supply chain distribution, given urban health systems collapsing and the resultant massive societal unemployment, reaching 42 million by June 2020 (Cox, 2020) . For employers, outlays for health coverage shrunk, so bottom lines benefited some, despite slacking production. The unemployed-now expanding Medicaid roles by 20% to 30%-will bring greater profits to drug store chains and pharmacy benefit managers (PBMs), though at the expense of their losing more lucrative employer-sponsored participants (Fein, 2020). Whether under fee-for-service or managed care, volume dispensing is key to these pharmacy players. In today's economy, the question to ask now is: Do the 170 some million Americans really like their employment-based private insurance, versus what Medicare single payer could be for them as a needed shield in these bad times? Republicans have recently proffered short-term, limited duration plans during the epidemic to compete with the Obama exchange plans; insurers may deny based on preexisting conditions, which the ACA had made illegal (Cohrs, 2020) . Depictions in the news media often present human-interest stories, but without further notice or indictment of those who perpetuate perverse conditions. In general, the establishment and corporate media downplayed both Sanders and Warren's universal Medicare and their outright criticisms of the insurance and pharmaceutical industries while favoring Centrist Democrats' criticisms of Medicare for All (Pedersen, 2019) . Greater depth of analyses must forcefully be put forward for restructuring strategies for change and to help rid profit-taking from the healthcare system. The pandemic has been said to present a turning point in health care due to its unprecedented impact domestically and worldwide; however, it is not just a need for data science conducted under the auspice of Silicon Valley (Aitken, 2020) . It was surely a wake-up call on unpreparedness and inequalities. Several advocacy groups have remarked that out the ashes of COVID-19, a Medicare-for-All movement should arise (Abrams, 2020) . To achieve such a national policy, its proponents must lead the public to see and understand how much the broader context of corporate health has to do with system corruption that created the mass vulnerability to the virus (PNHP, 2020). As progressives should readily realize, a financing solution alone is clearly insufficient, even if providers acknowledge and try to address social determinants of diseases. Overhauling the dominant players, restraining egregious profits, and restructuring care patterns across the system must be at the forefront of progressive policymaking. Greatly increased funding for new enrollees would be welcomed by the forces of greed, but without regulatory restraint to strive for ethical efficiencies, a newly constructed healthcare system may be unlikely. Broad structural reorganization must be planned in phases to move toward equity in health and to gradually rid corporate profit-taking throughout health care (Eyer, 1984) . Greater numbers of individual patients and families themselves now ponder the overall post-COVID-19 condition, when they face vastly delimited quality care-and cannot afford it. Folks may realize how much single-payer ideas are now worthy of consideration for benefiting themselves and everyone. Notwithstanding, Americans should never settle for a stripped down Medicaid-for-All mechanism that compromises care benefits. For those who are able purchase add-on private coverage, will it be enough to revitalize the medical industrial complex? So, messages for positive progressive principles must be shared to fend off Centrist Democrats spouting their similar corporate/Republican talking points to preserve the status quo or at best merely tinker on the margins of reform like a stateby-state public option. Thinking about how to reorganize the overall delivery system and to advocate for a new equitable public policy for all of the American people may have to reach beyond the average person's grasp; as Trump himself once said, "Nobody knew health care could be so complicated." Such an educational strategy necessitates clear articulation of what visionary reforms might concretely mean for families, communities, and the entire population-so necessary during the 2020 election campaign beyond merely "building on the ACA." Republican health policies historically have been so focused on special interests at the expense of the public's health, that it was worth the review in Chaps. 1 and 2 to see how vested interests benefitted from past administrations, notwithstanding the Democrats who also failed to enact more progressive policies, instead merely feeding the corporate monster. Even with the Affordable Care Act decreasing George W. Bush's number of uninsured by 41% in 2017, some 20+ million still were kept out of insurance coverage after 6 years of its passage-a legacy that prevailed into Trump's rule. Remember again that giving someone an insurance card is not in reality guaranteeing access to care. Access means assuring timely availability of affordable, comprehensive, quality care that is continuous by lowering social and cultural barriers to that care for a given population (Gulliford et al., 2002) . This means guaranteeing substantial infrastructural improvement so that physicians are there in all communities for relationships with patients and families. The ACA did not do this! Minorities and the poor have borne the greatest burden with class and race mostly accounting for the structural discrimination over why universal care has not been established here. News accounts demonstrate that minorities, the homeless, the aged in nursing homes and homes for the disabled, prisoners, and the poor have been most gravely stricken by COVID-19; these are groups that right-wing factions may consider as Charles Dickens's "surplus population" of the unproductive. To some degree, knowing much earlier these people were most at risk for infection, it may be assumed that a planned biological and economic genocide might have been orchestrated, since too little, too late, or no federal policies were enacted. Ongoing, this may demonstrate systemic social injustice and just may account for Trump's sinister delay in rolling out faster widespread virus testing with a supply chain to ensure adequate distribution (Callahan & Botella, 2020; McSwane & Gabrielson, 2020) . Incompetence in managing supply lines might have been overcome had the Administration been dedicated to different values and concerns for clearly those groups who were forgotten in the outbreak. For sure, a persistent ongoing financial crisis in health care is ahead for providers (Barnett, Mehrotra, & Landon, 2020) . Value-based care will require reconceptualization with telemedicine taking hold: Will the finance powers that be provoke a "renaissance" for value-based insurance? (Olmstead, 2020) . Many agree the pandemic will not preserve much of the same (The pandemic will recast the health-care industrial complex, 2020). It remains certain that corporate domination over the American healthcare system will never cease with both the Democratic and Republican parties still under sway of the corporate grip; business lobbies were able to direct legislative and executive actions before the coronavirus outbreak and are gearing up for more federal largess post-COVID-19. Apple and Google have proceeded with their tracking devices under government subsidization and medical record advances during the epidemic, even with skeptics and concerns over privacy (Apple, Google debut major effort to help people track if they've come in contact with coronavirus, 2020; The pandemic has spawned a new way to study medical records, 2020; The Economist, 2020a). Dumaine (2020) claims Amazon was built for the pandemic, becoming bigger and stronger. If the politicians and public swallow the belief in Big Data, greater largess will flow into their coffers as they forge further control over policymaking. Adding to the persuasiveness of this line of thinking is that clinicians and most citizens now recognize strengthening the public health infrastructure must come in preparedness for the next disease disaster. IT firms see large steady profit streams and improved public popularity for solving the COVID-19 crisis as well as future epidemics, in addition to their already addressing health system dysfunctions. The New England Journal of Medicine Catalyst (Barnett et al., 2020 ) surveyed clinicians to uncover: 1. Many providers will be financially devastated, with perhaps significant staffing shortages. 2. Feelings of expendability may be sensed "when being directed by ignorant administrators with little clinical understanding" (Barnett et al., 2020) . 3. Inventory management with proper logistical coordination will be better maintained, especially for personal protective equipment (PPE), ventilators and drug supplies, etc. 4. Should the coronavirus remain endemic, or its curve flattened, or cases diminish, cross-training may become a routine. 5. Telemedicine will grow with enhanced technologies. 6. Burnout will likely be better understood with more interventions commonplace. 7. Delivery of services will become more diverse and efficient. 8. Independent rural hospital closings, plus clinics. 9. Hopefully increased understandings of population needs. 10. Clinical leadership roles will be strengthened. The Current Crisis 11. At point of inflection, will systems learn from the lessons of the pandemic? Many hospitals face a precarious future given the coronavirus impact: margins will shrink, strategies and restructuring will come, staff may leave or die as was the case in hotspot areas, closings will be likely concentrated in red states, and unless financing can be assured, amalgamations will decline. The Congressional bailout paid billions to the wealthiest hospital chains, just as big hospitals got richer off Obamacare, forsaking many struggling health providers (Drucker et al., 2020) . Last year, the pharmaceutical industry spent $295 million on lobbying, more than any other industry (Accountable.US, 2020). This industry seems to be trying to redeem itself (Gordon, 2020) in the public's mind with highspeed coronavirus treatments and a vaccine (Thomas & Grady, 2020) . The IT industry already has numerous inroads in health care as discussed earlier, and many big firms are planning their "solutions" to the present system chaos, without privacy controls or other oversight. The pandemic will likely recast the entire healthcare industrial complex (The Economist, 2020b); McKinsey claims the virus recovery will be digital as IT firms beef up their growing extensions into health care (McKinsey & Company, 2020) . Infrastructural development and added federal economic stimulus will likely flow mainly into corporate coffers (as was seen with the Boeing bailout, airline subsidization, and channeling Small Business Administration loans through the biggest banks). Unless strong popular resistance is mounted and the Trump Administration is brought to justice, Democrats must take much different stands on the economic recovery, or the more powerful will win in negotiations for future subsidizations. Historians, beyond the scathing flow of media reviews to Trump's response to the COVID-19 epidemic, will have much to pour through. In the midst of Trump's first 3 years of uncertainty and policy confusion, the insurance industry seemed to do fine (Luthi & Dickson, 2017) , particularly on Medicare advantage plans (Livingston, 2018) . In 2019, health profits boosted CEO salaries by 15.7%, with the head of CVS pocketing $36.5 million. Articles in the trade magazines tried to explain the impact of COVID-19, which was that with healthcare organizations cancelling all elective procedures because of the huge increase in pandemic patients entering their hospitals, their outlay for these procedures is way down (Liss, 2020; . And insurance companies were given a boost when the Supreme Court upheld the ACA's "risk corridors" extra payments to insurers if sicker patients had signed up on their roles-a $12 billion infusion of cash that Republicans in Congress had unfunded in their continuing repeal of the ACA (Liptak, 2020). Note that the massive decrease in elective procedures and surgeries, and an epidemic of diagnoses and their too often cascade iatrogenesis (Welch et al., 2007) , can present phenomenal outlays for insurers; unemployed workers are not having premiums paid for them anymore, but at best Medicaid may be picking up the tab for the costly repair work now during the layoff. In the second Congressional Heroes Act appropriations bill under consideration, House Speaker Nancy Pelosi favored health insurers by providing subsidized 9 months' coverage for furloughed workers and the unemployed using COBRA for continued insurance coverage (Lacy & Walker, 2020) . It is key to note that not all health care is hurting; health insurers are thriving with the diminished utilization (Johnson, 2020) , but will they cut premiums and co-pays as some auto insurers have? Not much hope resides for insurers to step up to demonstrate their commitment to the nation's health (Navathe & Emanuel, 2020) . The booming federal deficit in trillions, and the tendency by Trump and the Republicans to distribute funding in their way to business, may leave fewer funds for health and social spending over several coming years. Schneider in the New England Journal of Medicine points out the tragic data gap that continues to undermine the US response even as this country tallies the most cases and deaths in the world (Schneider, 2020) , yet with little clarity, as the nation watches second and third waves of the virus after Trump's churches returning and rallies beginning in the "reopening of the economy." Lack of faith in Washington given the handling of the COVID-19 crisis (Tavernise, 2020) , as well as the state and local conduct toward the summer protests, may cement negative views toward politicians and public policy that may delimit progressive possibilities. Atkins (2020) argues we need a renewed Party that tells the truth and represents working Americans. It remains to be seen even under a winning Democratic Administration whether regulatory regress will return to the political environment as before 2016. As Lilla wrote in The New York Times, a state of radical uncertainty awaits the nation and world: Does anyone really know what's going to happen? (Lilla, 2020) . Given the Minneapolis cop killing George Floyd and the subsequent protests and rioting across the nation, profound clouds may hang over our nation's future up until the election. One must recognize that the history of American medical care is intricately intertwined with the American Labor Movement, which was highly instrumental in bringing out positive changes in health coverage and in public policy. Union membership has substantially lessened, though since the Reagan years, will under current circumstances, lead unions to re-emerge as a stronger voice in national policymaking. After the Second World War, unions embraced employment-based coverage but tended to abandon broader population advocacy. Yet today with new organizing campaigns, issues look different since the working class has growing minority representation, and they are truly hurting and vocal. Employment-based coverage has been presented by Centrist Democrats as a huge obstacle against the adoption of single-payer health insurance for all-nevertheless, with up to 60 million jobs lost and no coverage solutions for them in 2020, people may now feel much differently, especially about the role of private insurance. American unions had earlier on sought to address the very conditions of life, including health insurance as a benefit for families, workers' compensation, occupational health, child and maternal health care, and more benefit additions over time. Labor must now get behind such policy concerns and fight hard for universalist social democratic policy changes (Atkins, 2020 ). Nevertheless, the interests, objectives, and behaviors of corporate entities that were centralizing in health care fought against Labor's efforts and supported the shift to private ownership in the healthcare system. This different healthcare power structure brought along changes in traditions, philosophies, and the way history is being interpreted. The greater complexity and increased size of the health sector led to changes in the relative size of its different components (pharmaceuticals and hospitals vs. physicians) and the change in the position of the health sector in society in general (both parties' administrations have recognized health services as boosting economic growth). It was under these circumstances that proprietary health services took root both in the medical care sector (HMOs, ambulatory care, etc.) and in hospitals, along with the rise of powerful administrators replacing physicians in command. Will the American Labor movement get behind our critique of corporate health care? Given these developments, the position of "the physician" is subject to alteration. Will the profession be granted the evidence and relative power to meet clinical and financial goals? How will Labor respond to Medicine's current quandary? Clearly, information technology can and will make substantial contributions to help solve the data dilemmas in health care; however, such directions should proceed with oversight and multiple cautions. Understanding the origins of the American healthcare system before and after the viral outbreak will be more illuminating to rebuild it for more equitable distribution of services to all our citizenry. The trillion dollar IT behemoths are positioned to seize new opening opportunities with their huge cash buckets (McKinsey & Company, 2020) under the seemingly prevailing mood that they can "solve" our healthcare problems. Most of their activity stays under the public radar; meanwhile, their corporate public affair offices maintain vigil over popular favor for most of what they do, despite critics more dismayed by notable specific unsavory business behaviors. The well-cited discussion in Chap. 5 should provoke caution in addition to worries. Public policy has never truly addressed the issue of what should be the nature of the relationship between health services within a profit-based economy: What is the proper role for profit-oriented firms in the supply, provider functions, and insurance segment? How should their roles be assessed and at what costs and control are they permitted? What safeguards should be instituted to preserve a more appropriate and popularly desired balance? What is the necessary regulatory oversight for maintaining accountability? More importantly, is the structure and control over what we have now the best and the only way to organize healthcare services for the benefit of the American people and for their health promotion and well-being in the whole population? Do we want a system designed and run by those with huge financial interests in the system? For organizer Ady Barkan, COVID-19 is yet another reason to pass medicare for all COVID-19 as a positive turning point in healthcare Trump remaking federal policy on women's reproductive health Votes in red states to test support for Medicaid expansion We need a party that tells the truth and represents workers COVID-19 and the upcoming financial crisis in healthcare. NEJM Catalyst. 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