Joseph Jarvis MD MSPH received his medical and public health training at the University of Utah. He has enjoyed a thirty-plus year career in public health, serving at the state (Nevada and Colorado) and federal (OSHA) levels. He
has served as a consultant to clients from Guam to Ground Zero in NYC. Dr. Jarvis has been a leading advocate for better, simpler health care for all in Utah for twenty-five years. Visit:
If a 63-year-old male somewhere in America goes hiking and becomes lost, he can call for publicly funded emergency services and will likely be rescued at public expense. A homeowner can forget to turn off a burner on her stove, leave the home unattended, and return later to find that the local fire department has responded to an emergency call and put out a fire, saving most of her house and possessions, at public expense. There is no enrollment required for these public services, nor any premium, deductible, co-payment, or co-insurance.
It is the policy of the American people that our neighbors in need, whether citizens or not, should not suffer from an emergency because of inability to pay for the rescue. The emergency services personnel who respond to these calls for help selflessly throw themselves into danger to provide a desperately needed service. They are often public employees with modest salaries, or sometimes volunteers. Altruism, not profit, is what motivates emergency personnel to serve.
These services are rendered by every level of American government: federal, state, and local. They are paid for through taxation. Overhead is low, administrative waste is uncommon, and quality improvement in service delivery highly sought. Because health care delivery should share these same goals and aspirations, the business of health care in America should be the care of people needing help because of illness or injury. But that is not the case.
Business as usual in American health care is highly profitable. Pharmaceutical firms routinely outstrip median Fortune 500 company profits as a percentage of revenues by a factor of two- to four-fold, with total profits over $50 billion in 2020 alone. For profit health insurers had a most profitable year yet in 2022, mostly through increasing their revenues from public health programs like Medicaid and Medicare. For-profit ownership is now the dominant business model for most hospices (70%), home care companies (77%), skilled nursing facilities (82%), surgical or urgent care centers (89%), dialysis centers (94%), and free-standing laboratory or imaging facilities (100%).
Investor acquisitions of public and rural hospitals, as well as physician practices, have become common. More than 100 healthcare CEOs collected eight-figure paydays in 2021, the same year the US health care system pushed millions of people into medical debt, spurred patients to ration medications, and devoured more of the paychecks of American workers. There is no debating the assertion that the United States has the most profitable health care system in the world.
There is also no doubt that among developed nations American health care costs are the highest, now over $12,000 per person annually. Americans have the highest health care taxation rate in the world, amounting to $8000-$9000 per person per year, which is more than the annual per capita cost for health care in any other country without counting the out-of-pocket costs for health care paid by US employers and patients. Despite paying these highest in the world health care taxes and out of pocket costs, American patients commonly have no financial backing when sick or injured.
Tens of millions of Americans are completely uninsured, and more than one hundred million Americans are underinsured. The most common cause of personal bankruptcy in the US is the cost of illness or injury care, even though ¾ of those driven to medical bankruptcy had some form of insurance at the time of onset of their ailment.
Virtually all Americans know that things commonly go wrong when they seek health care. Medical bills are confusing and opaque, and sometimes carry arbitrary and hidden costs, such as the surcharge that hospitals call ‘facility fees. Insurance companies commonly deny claims without offering a reason. Claims denials force patients, meaning the sick and injured, to wage drawn out fights with insurers or simply pay hefty bills. Costs for procedures, medications, health insurance, medical devices, and consultations vary so widely and have such arcane hidden features that even patients who attempt to carefully investigate pricing commonly end up with bills far larger than expected. The American public is aware that no one in the US is protected against high health care costs—we are a health insecure nation.
American dependence on for-profit health care ownership is a big part of our health care problems. For-profit hospitals have the highest readmission rates for every condition, deliver more low value care, and have the highest overhead. For-profit dialysis centers have higher death rates and discourage kidney transplants. For-profit home care companies deliver lower quality care at a higher cost. For-profit nursing homes feature less nursing care and have higher death rates and hospital readmissions. For-profit hospices shun unprofitable patients and minimize the care they do deliver.
Drug prices are higher in the United States than anywhere else in the world. Overall, the American health care system is least likely in the developed world to be able to prevent mortality amenable to health care intervention—but we do make a lot of money off the care of the sick and injured.
The leaders of for-profit health care companies do not have a fiduciary duty to patients. Americans are health insecure because the managers of hospitals, nursing homes, hospices, health insurers, and all other health enterprises, are held to account not for meeting the needs of patients, but for making as much money as possible for stockholders. We Americans cannot have both highly profitable medical businesses and optimal patient care. What optimizes profit is not what makes for best patient care practice.
Health insurers are more profitable when they can avoid insuring people who are likely to need care and when they are able to deny funding care for people who are able to acquire an insurance policy. Neither of these business practices inure to the benefit of patients. Hospitals make more money by selling highly intensive services rather than finding a way to prevent patients from becoming so sick that they need highly intense services. Hospitals also make more money when they reduce labor costs associated with highly intense services by placing too many patients in the care of each nurse, threatening the well-being of the worker and increasing the risk of neglect and injury for the patient.
Pharmaceutical firms seek blockbuster profits by jacking up the price of medications, such as insulin, that certain patients must have no matter the cost. They follow this business practice even though they know that many patients will fail to be able to finance the purchase of life saving medication and will die. Or they simply fail to develop needed new medications, like antibiotics, simply because that class of medication will not ever produce maximal profits, condemning an ever-increasing number of patients with antibiotic resistant infections to premature death. We cannot have both maximal profits and optimal patient care.
The transformation of American health care to a system that puts the patient first does not require a radical change in our values, or a massive increase in public funding. We Americans have been trying for decades to give the gift of health care to ourselves. We have built hospitals with public funds, organized publicly funded medical research, paid for the training of doctors and nurses, and always sought a way to finance the care of the sick and injured, including for the elderly and those with kidney failure (Medicare), for the poor and disabled (Medicaid), for children (CHIP), for veterans (VHA), for Native Americans (IHS), and for populations served by an acronym soup of government programs (NHSC, FQCHC, Ryan White Fund, ACA, OPTN, etc., etc.) .
We value public funding for health care and that is the way we have principally chosen to pay for the care we all need—we tax ourselves more for health care than does any other citizenry. We also value private health care delivery. We want to choose for ourselves who will be our doctor. We want administratively simple, low overhead, public health care financing—which is why Medicare has been so popular since its inception. Seniors on traditional Medicare have ease of registration, are never kicked off the Medicare rolls, and can choose any doctor they would like to see.
Real and sustainable health system reform in America will permanently change the way we do health care business by replacing the for-profit motive with a drive to serve our patients the way fire departments already serve the public. Public taxation for health care already provides the revenues needed to support payment for medically necessary care for every man, woman, and child living in the United States; no additional revenues will be needed. Enrollment and other administrative burdens of private for-profit health insurance will be eliminated—everyone will be automatically enrolled in the public program and never denied needed care or disenrolled—saving $500 billion each year in currently wasteful overhead.
Better care—through appropriate staffing, use of primary care and mental health services now neglected, increased patient safety, and many other changes made possible by focusing attention on how best to serve patients instead of grasping for higher and higher profits—will keep American patients healthier and save an additional $500 billion each year over today’s poor quality US sickness-oriented system. Patients will be freed from the financial and bureaucratic barriers of current health care delivery; when care is needed each patient will be free to choose among all licensed physicians, therapists, dentists, audiologists, and health care institutions. Financing for health care will no longer be a function of employment, freeing employers to go about doing what they do best: making and selling goods and services.
It's time for common sense in health care reform. Let’s put patients first in our health care system. Let’s use our public health care dollars, now approaching $3 trillion per year, exclusively in the best interests of our patients. Let’s cut out the profiteering middlemen, the private, for-profit health insurance industry. No one needs coverage or health insurance; everyone needs health care. Let’s turn our doctors and nurses loose to attend to the needs of patients. We should insist that hospitals, nursing homes, and all other clinical enterprises focus on what patients need, not what pays the most.
Common Sense Health Care for Utah is a 501c4 organization recently founded by about fifteen concerned citizens of the Beehive State. We see the suffering and financial woes of our fellow citizens. In August 2020, the Utah Foundation published a report entitled “Utah Priority No. 1: Health Care (Costs and Accessibility)”, noting that health care costs were the top issue for Utah voters in 2016, and again in 2020. The Utah Foundation found that employee shares of premiums for family health insurance plans increased 40% over the decade from 2008 to 2018, while deductibles increased by 74% during that same period. In 2018, the typical Utah resident, man, woman, and child, spent $2800 out-of-pocket for medical costs, eighth highest in the nation. And that’s after paying the world’s highest tax rates for health care services. That same year, 13% of Utahns (more than 400,000 people) reported that they could not get the medical care they needed because it was too expensive.
In response to that report, Common Sense Health Care for Utah commissioned a study of health expenditures in Utah by The Matheson Center for Health Care Studies at the U of U. The Matheson Center reports that $28 billion were spent for health care in 2020, with an annual rate of increase in these expenditures at about 8% (from 2019 to 2020). Over the period from 1991-2020 Utah had the second highest annual growth rate in health expenditures in the nation at almost 7% per annum which, if sustained, will result in a doubling of per capita health costs every decade. The growth in health care costs clearly hurts Utah families and businesses, but some organizations are doing well with those health care cost increases. For instance, the Matheson Center found that from 2019 to 2020, health insurers in Utah saw an increase in net income (profits) from $1,236,000,000 to $1,776,000,000, or about half a billion dollars, equaling a 40% increase in profitability.
In response to these rising costs and the health insecurity they cause, Common Sense Health Care for Utah (CSHCU) proposes that health care financing in Utah be substantially altered. We propose to use the ballot initiative process to vote in a health care financing system that is universal, simple, and affordable. Our goal will be to replace the burdensome, complicated, and costly for-profit health insurance business model with one non-profit, private trust fund, owned and operated by and for the people of Utah, with low administrative costs. We know health care costs can be paid in this way because the Public Employees Health Plan (PEHP) already does business this way. Beyond lowering the massive overhead of business as usual in American health insurance, we propose that Utah’s new health care payer, which we have named Utah Cares, will change the way our hospitals do business. Rather than manufacturing ridiculously high prices on a charge list that has no basis in the true cost of caring for patients, hospitals will be paid through negotiated operating budgets and will manage growth and other changes in the system through capital budgets. Physicians and other health professionals will be paid through negotiated fees. Additionally, Utah Cares will work towards becoming the fiscal intermediary for Utah with the federal government and will attempt to capture all federal health funding already paid for care into Utah starting with Affordable Care Act (ACA) supplements, and expeditiously establishing its own Medicare Advantage and Medicaid Managed Care operations. A longer-term aspiration is to incorporate, or least coordinate with, funding from Veterans Affairs, the Indian Health Service, Tricare and other federal programs. All Utah residents (as defined in Utah Statute) not on Medicaid or Medicare will be eligible for initial voluntary enrollment, moving to auto enrollment with a benefit package defined by the ACA’s 10 essential benefits plus adult dental and vision. Care will be provided with no point of service payments allowed (no deductibles, copayments, co-insurance). Governance for health care costs can be organized in a publicly accountable fashion, similar to how the Utah Public Services Commission oversees utility costs.
Initial polling by Common Sense Health Care for Utah indicates that our ideas for substantially reforming the way we do health care business will be popular with the electorate of the Beehive State. People in Utah feel that health care is expensive or flat out unaffordable. They also recognize that health care is not like other consumer goods; it is something that everyone needs and should have. In our preliminary surveys, by a margin of 97% to 3%, Utahns believe that health care should be made affordable for every family. And by a margin of 87% to 13%, they believe that we in Utah can make health care affordable. We all know that by doing so we would be helping both ourselves and our neighbors, and we Utahns care about each other. By a large margin, Utahns would vote for an affordable health plan if it were on the ballot.
We at Common Sense Health Care for Utah are in the process of spelling out the details of our health reform policy. We are seeking to inform our policy making process with the best ideas from among our fellow citizens. This presentation is part of an ongoing and extended listening tour throughout the state of Utah so that we can learn more details about the health concerns of our population. What parts of the health care system are seen as too expensive? Where do patients find high prices, waste, and excessive complexity? Which approaches to solving the problems of excessive costs, financial barriers, and access gaps are most popular? We invite all Utahns to bring their ideas to our attention. We especially desire to hear patient stories about the difficulties of paying for and getting needed care. Health system reform, if it is to be effective, should reflect what patients need, not what is wanted by health insurers and pharmaceutical companies. We aim to incorporate the best ideas of all Utahns into a single policy that will cover every Utahn, protect the freedom to choose your doctor, and lower costs for everyone. Then we’ll bring that proposal before the voters in the form of a ballot initiative—one that is truly a law of the people enacted for our patients.
We invite everyone to join us in this effort. First, tell us your stories. Every family has had health care difficulties. Every family has a health care story to tell. Go to our website and locate the story telling feature and let us know what happened. Second, we need your time. There are people from every corner of the state at this meeting. We need your help to identify volunteers to lead our local public education efforts in every one of the public health districts across Utah. Go to our website and be that volunteer. And finally, no ballot initiative is possible without massive funding. Save your political donations for Common Sense Health Care for Utah. If you don’t usually donate to political parties or candidates, donate to Common Sense Health Care for Utah anyway. Go to our website (http://commonsensehealthcareutah.org) and make a generous dollar donation. Get involved, and let’s bring common sense back to health care in Utah.