Late one afternoon, an office staff member at the rural clinic where I was a physician asked if I would double-book a patient who injured her back. Less than an hour later, a 62-year-old woman struggled down the clinic hallway to get to the exam room, using a pair of old walking canes her husband had relied on before he passed away. She had bent over to lift a heavy trash can and felt a sudden tear in her back, followed by severe pain and back spasms. The diagnosis was clear from my exam: a herniated disc of the lower spine. She needed an MRI and a referral to a spine surgeon.
The staff member called the patient’s health plan to get approval for both, but they were denied. We were told she needed bed rest and pain medications. When I personally called the health plan for a doctor-to-doctor appeal, I could not get through. I recommended she go to the emergency department (ED), but like many of my determined rural patients, she refused. I then told her I would call her health plan the following morning to get the needed approvals, and that she should have her neighbor drive her back to the office the following afternoon.
The next morning, I spent well over an hour arguing with the health plan. Their answer again: bed rest, pain medications, and physical therapy (PT). PT was impossible; she could not even roll over when lying down, needing to use her arms for almost any movement as though she were paralyzed from the waist down. So, I sent her to the closest hospital ED that had spine surgeons on staff. She had her MRI, and a spine surgeon operated on her the next day.
Although her medical outcome was good—after recovery she resumed normal activities—her financial outcome was disastrous. She was stuck with an out-of-pocket bill of over $100,000. The true cost of her care was a fraction of that, but it’s routine for hospitals to charge outrageous fees for every last IV push and bandage. And her health plan only contributed a small sum because she went to an “out-of-network” hospital. This is our American system of corporate medical care.
Healthcare is now just like any other industry: its goal is to maximize profits without regard to the harm caused.1 With Wall Street and private equity lurking behind the scenes, profit is increased by denying needed medical care to patients.2 Administrators may determine what medical care a person receives. Patients’ experiences are worse and healthcare professionals are suffering, but why would that matter to people who see illness and injury as opportunities to get even richer?
When I completed medical school in 1975, the US healthcare system was relatively simple: Need a doctor’s appointment? Call one of many doctors, and you’d get an appointment the same week or even the same day. Some doctors’ offices would even take x-rays and perform simple tests. Most physicians, both primary care doctors and specialists, worked in independent offices owned by a single physician or a small group of partners. If you needed additional care, your doctor would oversee it at your locally controlled hospital,* which was likely nearby; in 1977, there were more than 7,000 hospitals.3
Fast-forward to today. Healthcare has morphed into a world of detours, roadblocks, frustrations, and long waits.4 The number of hospitals has declined to about 5,000,5 leaving many people in rural and low-income communities dangerously far away from necessary services.6 And under the profit-driven corporate culture that now dominates what has been termed the healthcare industrial complex, the very idea of caring for people is all but forgotten by industry leaders. Now prior authorizations from insurance companies may be required for medications, specialists, procedures, surgeries, and imaging such as MRIs and CT scans. When a patient finally sees a clinician, the clinician is forced to focus on the computer, not the patient. And a confusing array of in-network versus out-of-network physicians and hospitals exists, along with outrageous out-of-pocket expenses that too often cause bankruptcy and even homelessness.7 The negative consequences for patients are obvious. More subtle is the toll these changes are taking on the doctors, nurses, and other health professionals who are suffering burnout and moral injury. My colleagues and I chose healthcare to heal people, not to funnel gold to Wall Street.
How did we evolve to such a horrible system of healthcare in the United States? I wrote a book on this topic, Corporatizing American Health Care: How We Lost Our Health Care System, that traces my time as a physician over the past 40 years.8 The book explains how our system of healthcare has transitioned from caring for people to putting profit first. In the book, as well as in this article, I also explain how we—healthcare professionals and voters—can take our healthcare system back.
By my estimate, about half of our costs in healthcare are unnecessary. How do I know? Just look at our peers across the Atlantic. The United States spends $12,000 to $13,000 per person per year to provide healthcare.9 But Western European countries, where care is equal or better, spend about $6,000 per person per year, and out-of-pocket costs for individuals tend to be much lower than in the United States.10 Hospitals are run efficiently, and healthcare professionals make decent wages—but these countries’ lawmakers have prevented anyone from making an abusive profit from illness and injury.
I began my career as a physician in the summer of 1980. I had already completed medical school, a residency in internal medicine, and a 30-country circle-the-globe trip with not much more than a backpack and an airline ticket. I had my first introduction to the European system of healthcare after needing vaccines for travel to Africa, and I refreshed my training in tropical medicine by working in a remote jungle area of Sierra Leone.
My choices in 1980 were endless. I could take out a loan and start an independent practice in primary care or continue training to become a specialist (I was offered a fellowship in cardiology). But I chose to become a hospital-based ED physician at the University of California Davis Medical Center in Sacramento. I loved it, especially in the early years, and served as chief of emergency medicine for 18 years. My final eight years of clinical practice were as a primary care physician in a rural clinic in the foothills of the Sierra Nevada mountains, where most of my patients heated their homes with firewood cut from the surrounding forests. Those were my best years as a physician. Getting to know my patients well and helping them in their struggles with an ever more complex health system was fulfilling.
Throughout my professional life, I have also been fortunate to serve as a visiting professor at multiple hospitals in eight Western European countries. The more American medicine is consumed by profit seeking, the more thankful I am for having seen firsthand that there are ways to provide excellent, affordable care.
Profits Over Patients
Walking home from the grocery store, my 95-year-old father was run over in a crosswalk.† Bloodied and almost unconscious, he was taken by ambulance to the Los Angeles County+University of Southern California Medical Center and hospitalized for five days. Soon, a $2,000 bill arrived for the ambulance. My father’s health plan clearly covers ambulances, minus a $100 deductible. So why did he receive a bill? Because the ambulance was not preauthorized. But who, exactly, could have called for preauthorization? The kind stranger who called 911? The paramedics concerned with stopping his bleeding and his, as they put in their report, “altered mental status”? Perhaps my father was supposed to call?
But that wasn’t the end of this saga. Next, his health plan deemed the medical center out of network and denied coverage of his hospitalization. After many hours on the phone struggling with the health plan, my sister paid the ambulance bill from my father’s bank account and hired an attorney to handle the hospital bill. Only then did the health plan relent on the medical center. My family was not bankrupted by this experience, but far too many of my patients are. The denial of coverage—even for true emergencies—is outrageous. (As noted later in this article, the No Surprises Act of 2021 should prevent this in the future, but it may be challenged in court.)
Sadly, I know that all healthcare professionals have stories like this. We need to share them. We need our fellow community members and voters to know. We need our elected officials to know—and to act. So I’ll share a couple more stories.
Dave, an acquaintance of mine, recently told me about his struggles getting cataract surgery to avoid losing his driver’s license. The eye surgeon, in independent practice, required him to have a medical exam, laboratory tests, and an x-ray as part of a pre-op evaluation. He had two weeks to complete these tasks, but the soonest appointment he could get with a primary care physician (PCP) was in four months! In his town, all independent PCPs had vanished, swallowed up by the single hospital system where administrators made the rules on how medicine would be practiced. Desperate to keep his license, Dave waited in a long line in the hospital’s urgent care clinic to have his forms completed by the doctor. He then had to make appointments for laboratory work and x-rays. His bill: $1,800. His health plan refused to pay because they considered his visits unnecessary; they claimed he was healthy.
Susan, a patient of mine at the rural clinic, was stung by a bee. Luckily, a neighbor saw her faint and called 911. The paramedics gave her epinephrine and took her to the ED, where with just a little more treatment she was soon ready to go home. Advising her to wear an emergency bracelet, the ED doctor prescribed an EpiPen. He also showed her how to use it and urged her to carry it always. But he didn’t ask if she could afford it. At her local pharmacy, she was shocked to learn that it would cost $600, and her health plan refused coverage. With only a few dollars in her checking account and her credit card nearly maxed out, she left empty-handed. During an office visit two weeks later, I prescribed two generic, inexpensive vials of epinephrine and showed her how to use a syringe.11
These three stories reveal systemic, nationwide problems. The first highlights the dysfunction in our health plans, which routinely deny coverage—a problem we see repeated in stories two and three. The second highlights how massive hospital systems have created local monopolies, allowing them to determine when and how people receive care, as well as what to charge. The third highlights another form of monopoly—drugmakers’ control over medications that should no longer have patent protection—plus the need to educate prescribers about questions to ask and alternatives to consider when writing prescriptions.
What unites these stories is their solution: legislation. Western Europe has proven that there are better ways to ensure that people get the care and medications they need. On this side of the Atlantic, the US Congress has an important role to play in making laws that govern healthcare delivery—a role it has too often shirked, allowing the American people’s health to suffer for the sake of corporate profits. Corporate lobbying and campaign contributions to members of Congress12 have no doubt helped double the cost of healthcare delivery in the United States compared to Europe. Before turning to legislative solutions, let’s examine our monopolies—and learn a little more about the Western European alternatives.
The Destructive Power of Hospital Monopolies
Across the United States, we have about 5,000 acute care hospitals: roughly 3,000 nonprofit, 1,200 for-profit, and the rest academic medical centers or government hospitals.13 While more than half are designated nonprofit, don’t be fooled; they run on similar business models as for-profit hospitals with extremely well-paid executives and an army of highly paid administrators.14 With exemptions from federal, state, and local taxes, they are supposed to offer public benefits like charity care. But research has found that “in 2018, nonprofit hospitals overall dedicated a smaller proportion of their expenses to charity care than did government-owned or for-profit hospitals,” and a study published in 2021 found that “nonprofit hospitals were more likely to sue patients for their medical bills than their for-profit counterparts.”15
It’s like the very idea of healthcare has been turned upside down. What happened?
Both for-profit and nonprofit hospitals have formed pricing monopolies through mergers and acquisitions (which should violate federal antitrust laws). Although a handful of publicly owned district hospitals can be found in some states, the locally controlled community hospital has largely faded into the past.16 Throughout much of the United States, consolidation of hospitals reduces consumers’ choices, leading to increased prices17 and stagnant wages for healthcare professionals.18 Among the largest for-profit and nonprofit health systems are Hospital Corporation of America (HCA) Healthcare, which controls 184 hospitals, Ascension with 139, CommonSpirit Health with 137, and Trinity Health with 92.19 Smaller but still of concern are regional systems like the University of Pittsburgh Medical Center. It has a virtual monopoly in a metro area of over two million people, with 40 hospitals and nearly 9,000 beds.20 And apparently, it acts like it: it has been sued, unsuccessfully, by both the mayor and the state attorney general for not meeting its charity obligations.21
Today, hospitals without regional competition can arbitrarily set their fees for services,22 although contracts with some health plans may limit their fees, as does Medicare. A recent report described a hospital that charged an extra $722 for a nurse to administer a drug intravenously.23 Yes, $722 for less than a minute of work, when the nurse’s time is already included in the hospital facility use or daily bed fee. For simple visits to a hospital ED, patients with common complaints such as chest or abdominal pain may receive hospital bills as high as $30,000, even if no serious causes of the symptoms are uncovered.24
How do hospitals create these bills? While no article could be long enough to detail all of the profit-making tricks, here are a few. Hospitals may charge for every item or procedure used in the care of a patient, including medications, IV tubing, IV fluids, an IV push of drugs, bandages, procedural trays, nebulized treatments for asthma, EKGs, splints, washing kits, and even warm blankets.25 These extra fees are in addition to outpatient facility use fees or daily inpatient “bed rent,” and can add up to thousands of dollars. In the past, many of these items were bundled together as a single charge and included in the hospital bed fee, as Medicare and some health plans now require.26 Another trick is adding surcharges that result from special designations such as cardiac ICUs, pediatric ICUs, and trauma centers. For example, an extra charge may be added when an injured patient arrives by ambulance (trauma activation) and can range from a few thousand dollars to as high as $50,000.27 Similarly, the fee for a blood test may be much higher when ordered in the ED than in an outpatient area. It’s obvious that all of these fees are bad for patients—who pay either directly or through higher health plan premiums and deductibles—but there are also less obvious but still significant negative consequences for patients and healthcare professionals.
In the 1980s and 1990s, a long list of independent practice physicians was available to serve most Americans, and those physicians competed with each other to be the best in the three As: affability, affordability, and availability. Where have they gone? Fee structures built into Medicare to win over the hospital industry made independent practices very difficult to sustain, while at the same time creating many ways for hospitals to increase profits (e.g., facility use fees).28
Today, with those large profits, hospitals can hire physicians—often through affiliated medical groups—at attractive salaries and benefits. When I started my career, hospitals served doctors, providing support with staff, facilities, and hardware so that doctors could best care for their patients. Now, so many of my colleagues feel that doctors serve hospitals, who serve their CEOs, whose goal is money.29
This Wall Street business model exploits healthcare workers along with their patients.30 In some respects, physicians and mid-level clinicians have become the money generators for the healthcare industrial complex. Profits can be made from every order a physician enters into the computer, including laboratory tests, imaging, procedures, supplies, and drugs. And the largest cut of these profits goes to the massive hospital systems that dominate US healthcare.
Community control has faded as each year more and more physicians, nurse practitioners, physician assistants, and nurses are being employed by Wall Street firms, either stockholder or private equity contract management groups (CMGs). This includes primary care providers, hospitalists, and hospital-based specialists in areas such as emergency medicine, anesthesia, and radiology. Corporations, including Walgreens, CVS, Amazon, and Optum, hire physicians and nurses and then contract with hospital entities for their services, making a hefty profit from increased fees to patients.31 Corporate employment of physicians and other clinicians results in loss of autonomy and independent thinking—the key elements of good patient care. It opens the door to requiring clinicians to follow protocols that result in increased profits, such as ordering unnecessary tests and prescription medications.
One of the most dangerous aspects of this corporate business model is that both for-profit and nonprofit health systems have increased retaliation against whistleblowers, including firing physicians, nurses, and other healthcare workers who complain about patient safety issues.32 For example, in 2020, the national news media provided extensive coverage of the firing of a Washington state ED physician who rang the alarm bells because he believed his hospital’s COVID-19 response was inadequate.33 Two corporate entities were involved: PeaceHealth St. Joseph Medical Center in Washington and the national CMG TeamHealth, which employs physicians to work in EDs throughout the United States. There are many other examples, including a colleague of mine who was fired for complaining about a patient safety issue in the ED and not playing “team ball”—in other words, not cooperating with corporate goals. Likewise, the media is filled with stories of nurses being fired for raising patient safety issues. Recently, NBC News reported about two nurses who were fired for filing written patient safety complaints; in one case, there was a next-day termination.34
Short of firing, corporate monopoly medicine brings endless frustrations for healthcare professionals. Topping the list is computer software that now micromanages every aspect of care. Instead of focusing energy and attention on bedside patient care, physicians and nurses must spend valuable time clicking through prompts and entering data. A nurse recently told me about the problem of taking a finger stick glucose level. In the past, she would prick the skin, let a drop of blood stick to the glucose strip, and record the blood sugar on paper, all in about a minute. Now it takes at least five minutes of clicking through logins and a series of windows before and after seeing that drop of blood. “It’s totally frustrating,” she said, “and I am not given any extra time to do this. Meanwhile, I have four or five other patients who are vomiting, screaming in pain, or needing to urinate who I ignore because I am evaluated on what’s in the computer.”
Additional stressors include inflexible scheduling, long shifts, forced overtime, nurses caring for more patients than is safe, and skipped breaks. Especially troubling is that patients and their families are lashing out, and violence‡ against healthcare professionals is increasing.35 The results of all these stressors are decreased effectiveness at work, burnout, moral injury,§ and physical injury. But too many hospital CEOs have their heads in the sand, clueless about what life is like on the frontline of bedside healthcare.
The Astronomical Prices of Drug Monopolies
Forty years ago, most prescription drugs were very affordable. There was significant competition throughout the pharmaceutical industry, from manufacturing to sales. Along with reasonable prices, good customer service and quality products were important. But today, profit seems to be the only priority. Having successfully lobbied Congress, Big Pharma is able to maintain patents for decades—establishing a marketplace monopoly—and to set truly astronomical prices.36
When a new drug is approved by the US Food and Drug Administration, laws passed by Congress can provide exclusive patent protection. No one else can make and sell that drug, usually for 20 years. Pharmaceutical corporations claim this is necessary because drug development and testing is expensive. However, in some cases development costs may be recouped in just a few years. And in other cases, development costs for the company are minimal, such as when the federal government supports drug research or the pharmaceutical company combines two or more drugs to make a “new” (patented) medication. Another common profit-making strategy is used near the end of the patent protection period; the pharmaceutical corporation makes minor changes to the drug, or only to its delivery system, and is granted many additional years of a patent-protected monopoly.
For example, a drug called Lupron was invented in 1973; it received a patent extension in 1989 because of a change made to the delivery system and was renamed Lupron Depot. Through continuous legal loopholes, it is still expensive; the wholesale price of the slow-release version of the drug is $5,800. How do I know that’s not a reasonable price? In some countries where lawmakers don’t allow price gouging, a three-month supply of Lupron Depot is available to physicians for $260.37 Another example is insulin, which was discovered about 100 years ago. A month’s supply of insulin should sell for about $25, but by making minor alterations to the drug in different ways, corporations have gained patent protection for the “new” insulin and have charged my patients as much as $500 for a month’s supply. Today, three companies maintain a monopoly on insulin, and the US Congress has only just begun counteracting that monopoly by capping the price for people on Medicare.38 This is despite the fact that we spend six times more on insulin than people in Canada, Australia, or the United Kingdom.39
Most profitable are a new class of drugs using monoclonal antibodies (often referred to as biologics).40 Each time I open a copy of the New England Journal of Medicine, one of the United States’ most respected peer-reviewed medical journals, I see multipage glossy ads for biologics as cures for issues ranging from arthritis to cancer. Often these new drugs cost $60,000 a year or more. Humira, introduced in 2003, is one of the first examples; it now lists on GoodRx for nearly $80,000 per year with a coupon.41 Humira can provide a new life for people with severe rheumatoid arthritis, but who can afford that price? Health plans have had their arms twisted to cover much of the cost, but out-of-pocket costs for patients remain high. In other countries, Humira sells for a fraction of the US price.42
In addition to charging astronomical prices, pharmaceutical companies increase drug sales through direct ads to consumers. What is missing in these ads is the true retail price and the fact that companies make the most profit from very expensive drugs, those costing more than $50,000 a year. In an effort to get physicians to prescribe drugs, some pharmaceutical companies have resorted to unlawful methods of influence. For instance, in United States v. Biogen, the Department of Justice charged Biogen with kickbacks to physicians, resulting in a $900 million settlement in September 2022.43
Western European Healthcare Costs Less and Delivers More
We could receive outstanding healthcare in the United States for far less money if we regulated the healthcare industry, as most Western European countries do.44 I have collectively spent months as a visiting professor in Western European hospitals and clinics and have always been impressed with both the quality and low cost of care. Europeans have access to the same imaging technology, advanced surgeries, incredible cancer treatments, and new prescription drugs available to Americans. Most impressive are the minimal out-of-pocket costs to residents, which range from a few bucks to a few hundred dollars a year. Europeans were shocked when I told them it could take up to four months to get a new patient appointment in the United States with a primary care physician.
Given the increased attention in popular media to Western European healthcare in recent years, I think it is important to discuss some myths versus facts.45
Myth 1: There are long delays or wait times for medical appointments or surgery in Western Europe.
Fact: Wait times, if any, are typically shorter than in the United States. For visits with primary care providers, wait times are far shorter.46 And for most surgeries, the waits are generally no longer than in the United States.47
Myth 2: Advanced drugs, cancer therapy, high-technology imaging, procedures, and surgeries are not available in Western Europe.
Fact: Drugs, cancer treatments, surgical procedures, and other medical treatments are equal to or even better than those offered in the United States.48 I have seen this from the frontlines on both sides of the Atlantic.
Myth 3: The government decides whether a person will get the care they need.
Fact: Doctors decide the entire plan of care for their patients. In contrast, in the United States, doctors’ plans may be blocked by for-profit health plans or HMOs, and patients may not receive the care they need.49 Yes, in the United States, a health plan administrator, without examining a patient, can determine what medical care is needed.
One of my most memorable days was spent in The Hague, Netherlands, at a municipal healthcare call center staffed by nurses, physicians, support staff, and ambulance dispatchers. People with medical problems called to speak with one of the many nurses at the center. Depending on the severity of their problem, they were offered one of several options: (1) advice on care at home, (2) an appointment with their PCP made by the call center, (3) a same-day referral to their physician or an urgent care clinic, (4) a referral to an ED, or (5) ambulance dispatch. An electronic map of the city was used to direct ambulance traffic. This was one-stop shopping that put the patients first. The out-of-pocket cost was usually nothing, but it could be as high as $100 if the individual was sent to the ED.
Several Western European countries really do spend half the money, or even less, per person per year compared with the United States and provide equal or better healthcare.50 How? They have devised many systems: (1) single-payer healthcare provided by the government, (2) public insurance plans, (3) private insurance plans, (4) mixtures of public and private plans, and (5) public hospitals and/or private hospitals.51 What they all have in common is fixed prices for doctor visits, hospital stays, procedures, x-rays and imaging, and prescription drugs. Prices are set by official committees under the purview of each government with representatives from all segments of the industry—including doctors, hospitals, pharmacists, and lawmakers—who together negotiate prices that apply across each country.** Funding of healthcare generally comes from a mixture of sources depending on the country, including national taxes, employer contributions, and employee contributions.
While their pay may be less than US healthcare workers’, healthcare workers in Western Europe traditionally have enjoyed many benefits, including generous vacation time of four to six weeks per year, shorter work weeks, less onerous computer-driven data entry, and a culture devoted to patient care—not grinding out profits for corporations. In the years leading up to the pandemic, several Western European healthcare systems were strained and faced staffing shortages and other labor issues similar to those in the United States. And, as in the United States, the COVID-19 pandemic greatly increased the strain, especially as healthcare positions went unfilled.52 Looking ahead, many Western European countries will likely need to increase their spending to resolve their staffing crises—but they could increase their spending by half and still be far below the United States.
Healthcare and the US Congress
After 35 years of watching our healthcare system deteriorate, I determined to fight back. Seeing that my power as a physician was limited to local changes, I decided to run for Congress to represent California’s fourth district. I didn’t win, but talking with thousands of people about their terrible healthcare experiences showed me that I can’t give up on rebuilding our healthcare system. So I changed my tactics: I wrote my book, Corporatizing American Health Care, and have become dedicated to showing all Americans that we can have great, affordable care.
Too many hospital systems are billion-dollar enterprises with lots of power to lobby Congress, buy out competition, charge outrageous prices, dictate stressful orders to employees, and require physicians and other clinicians to follow profit-making protocols. And too many pharmaceutical companies are even worse, denying people access to lifesaving medications even as they rake in shocking profits.
Collectively, hospitals and nursing homes spent $120 million lobbying Congress in 2021, using an army of nearly 1,000 professional lobbyists; over the past 20 years, they have spent $2 billion to advance their agenda.53 The pharmaceutical and health products industry spent $361 million lobbying Congress in 2021 and $5 billion over the past 20 years.54 That’s a lot of influence. And that influence has resulted in laws passed by Congress that have enabled huge profits. Even steps to have Medicare negotiate drug prices, as enacted in the Inflation Reduction Act of 2022, got watered down.55 The initial intent to negotiate prices for thousands of Medicare drugs ended up applying to only 10 drugs in 2023 and 15 drugs each in 2024 and 2025 as a result of lobbying (along with implied campaign contributions).56
But I remain optimistic. Congress has acted against the evils of corporate monopolies in the past and can do it again. Examples include the 1890 Sherman Antitrust Act outlawing “conduct and attempts to monopolize a market” and the 1914 Clayton Antitrust Act, which outlawed “mergers and active acquisitions that lessen competition.”57 Only over the past 40 years have independent physicians, hospitals, and pharmaceutical companies given way to the corporate monopolies. With enough pressure from healthcare professionals and their patients (that is, almost all Americans), all US representatives and senators could stand up against the healthcare industrial complex and enact legislation with the power to protect patients and improve our collective health.
Success stories are limited but show that in some cases the “people’s lobby” can outsmart the corporate lobby. In December 2021, Congress passed the No Surprises Act, with the intent of putting an end to outrageous ED bills as a result of seeking emergency care at an out-of-network hospital.58 Congress acted because of tremendous public pressure, even though the healthcare industry lobbied extensively against it, including airing TV ads. Another success story occurred with passage of the Inflation Reduction Act of 2022. Despite the watering down, that legislation is already having a major impact: on March 1, 2023, Eli Lilly went beyond the legislative mandate, announcing a 70 percent reduction in the most common formulations of insulin and a maximum copay of $35 per month for those with insurance. Before the end of March, the two other major insulin producers, Novo Nordisk and Sanofi, had also cut their prices.
Healthcare professionals should be leading the people’s lobby. We know that many of our patients are being over-tested and overcharged. We know that many patients we see in the ED wouldn’t be there if they had access to affordable primary, preventive care or if they could afford all of their medications without having to choose between medications, food, and rent. We know that far too little profit is being reinvested in our communities and far too much of it lines the pockets of executives and investors.
To save our patients and our professions, here are several steps we could take.
1. Pressure Congress to regulate healthcare monopolies. If you have a bad experience with healthcare or prescription drugs, either as a patient or a clinician, write letters about your experience. Explain what happened to your union representative, human resources department, or boss. Follow up with a real paper letter, which can be more powerful than an email. Write to your lawmakers, including your federal and state representatives and senators, newspapers, local television stations, civic organizations, and anyone else you think might be helpful.
2. Advocate for setting limits on what corporations can charge for medical care, including hospital and physician fees, prescription drugs, and health plan premiums. Medicare already sets hospital and physician fees, and hospitals compete for Medicare patients. Regulating prices is the key element that results in Western European healthcare costing half of what it costs in the United States.
3. Advocate for a consumer healthcare protection bureau. The Consumer Financial Protection Bureau is charged with helping people who have been cheated by banks, finance companies, and lenders. We need a government agency to hold the healthcare industry accountable and help people who are cheated by healthcare corporations.
4. Speak up. If in your role as a healthcare worker you are forced to do something that favors profit over good patient care, report it to your union and the appropriate authorities. Anonymous reporting systems may be available. If you fear retaliation, seek help with union or patient advocate organizations. Be proactive on behalf of your patients, not the corporate entities that may employ you.
5. Be politically active. Vote. Attend town halls organized by your elected officials and candidates. Share your experiences as a healthcare professional as widely as possible—and ask everyone who listens to vote for putting patients over profits.
Congress has the ability to set the rules for the delivery of healthcare in the United States.†† Over the past 40 years, too often these rules have favored corporations and corporate monopolies over the people who make up this country. Difficulties in accessing medical care, outrageous hospital prices, very expensive drugs, roadblocks created by health plans, and high out-of-pocket expenses have created hardships for too many people in the United States. At the same time, healthcare workers have been squeezed to do more in less time, making the job of caring for people more rushed and less rewarding. We cannot continue to be silent servants to corporate America. Together, we must ensure that patient care decisions are based on need, not driven by profit. Patients trust us to have their best interests first and foremost. Let’s not betray that trust.
Robert W. Derlet, MD, a professor emeritus of emergency medicine at the University of California, Davis, is the author of Corporatizing American Health Care: How We Lost Our Health Care System and over 100 articles. The former chief of emergency medicine at the UC Davis Medical Center, he has published research on healthcare delivery for the past 30 years.
*Throughout this article, I refer to medical centers, health systems, and hospitals as hospitals. (return to article)
†For more details on this incident, see my book Corporatizing American Health Care: How We Lost Our Health Care System. (return to article)
**One component of our system in the United States also has uniform set prices: Medicare. Imagine how our healthcare costs would fall if fees for all visits to physicians and hospitals in the United States were set by the Medicare fee schedule. (return to article)
††For additional ways to improve care while controlling costs, see “COVID-19: From Public Health Crisis to Healthcare Evolution” in the Fall 2020 issue of AFT Health Care. (return to article)
1. See J. Silver-Greenberg and K. Thomas, “They Were Entitled to Free Care. Hospitals Hounded Them to Pay,” New York Times, December 15, 2022, nytimes.com/2022/09/24/business/nonprofit-hospitals-poor-patients.html; and “Profits Over Patients,” New York Times, nytimes.com/series/profits-over-patients.
2. “Patients for Profit: How Private Equity Hijacked Health Care,” KHN, Kaiser Family Foundation, khn.org/news/tag/patients-for-profit; and A. Flynn, R. Mabud, and E. Chessen, The Plight of Health Care in Rural America: How Hospital Mergers and Closures Harm Women (New York: Roosevelt Institute, June 2019), rooseveltinstitute.org/wp-content/uploads/2020/07/RI_Hospital-Mergers_Issue-brief_201905.pdf.
3. C. Bays, “Why Most Private Hospitals Are Nonprofit,” Journal of Policy Analysis and Management 2, no. 3 (Spring 1983): 366–85.
4. E. Rosenthal, An American Sickness (New York: Penguin Books, 2018).
5. KFF, “State Health Facts: Hospitals by Ownership Type, 2021,” Kaiser Family Foundation, kff.org/other/state-indicator/hospitals-by-ownership/?dataView=1¤tTimeframe=0&selectedDistributions=statelocal-government--non-profit--for-profit--total&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
6. Flynn, Mabud, and Chessen, The Plight of Health Care.
7. Consumer Reports, “Why Is Healthcare So Expensive?: Why It’s So High, How It Affects Your Wallet—and Yes, What You Can Do About It,” September 2014, consumerreports.org/cro/magazine/2014/11/it-is-time-to-get-mad-about-the-outrageous-cost-of-health-care/index.htm; and J. Bielenberg, “Medical Debt and Homelessness,” Public Health Post, August 23, 2021, publichealthpost.org/research/medical-debt-homelessness.
8. R. Derlet, Corporatizing American Health Care: How We Lost Our Health Care System (Baltimore: Johns Hopkins University Press, 2021).
9. Centers for Medicare and Medicaid Services, “NHE Fact Sheet,” December 14, 2022, cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet; and Peter G. Peterson Foundation, “How Does the U.S. Healthcare System Compare to Other Countries?,” July 19, 2022, pgpf.org/blog/2022/07/how-does-the-us-healthcare-system-compare-to-other-countries.
10. Peter G. Peterson Foundation, “How Does the U.S. Healthcare System Compare”; M. McGough et al., “How Does Health Spending in the U.S. Compare to Other Countries,” Health System Tracker, Peter G. Peterson Foundation and Kaiser Family Foundation, healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/; and M. Gunja, E. Gumas, and R. Williams, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (New York: Commonwealth Fund, January 31, 2023), commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022.
11. Derlet, Corporatizing American Health Care.
12. J. Stein, “Congress Showers Health Care Industry with Multibillion-Dollar Victory After Wagging Finger at It for Much of 2019,” Washington Post, December 20, 2019.
13. KFF, “State Health Facts: Hospitals Ownership by Type, 2021.”
14. D. Ofri, “Why Are Nonprofit Hospitals So Highly Profitable?,” New York Times, February 20, 2020; and “Profits Over Patients,” New York Times, nytimes.com/series/profits-over-patients.
15. E. Gee and T. Waldrop, Policies to Hold Nonprofit Hospitals Accountable (Washington, DC: Center for American Progress, October 18, 2022), americanprogress.org/article/policies-to-hold-nonprofit-hospitals-accountable.
16. K. Schwartz et al., “What We Know About Provider Consolidation,” Kaiser Family Foundation, September 2, 2020, kff.org/health-costs/issue-brief/what-we-know-about-provider-consolidation.
17. Schwartz et al., “What We Know.”
18. E. Prager and M. Schmitt, “When an Industry Consolidates, What Happens to Wages?,” KelloggInsight, April 4, 2019, insight.kellogg.northwestern.edu/article/merger-consolidation-wages-effect.
19. Becker’s Hospital Review, “100 of the Largest Hospitals and Health Systems in America,” March 23, 2022, beckershospitalreview.com/100-of-the-largest-hospitals-and-health-systems-in-america-2021.html.
20. UPMC, “By the Numbers: UPMC Facts and Figures,” University of Pittsburgh Schools of the Health Sciences, upmc.com/about/facts/numbers; and Pittsburgh Region, “Pittsburgh Regional Overview,” pittsburghregion.org/doing-business-in-pittsburgh/pittsburgh-regional-overview.
21. Ofri, “Why Are Nonprofit Hospitals?”
22. S. Kliff, “I Read 1,182 Emergency Room Bills This Year. Here’s What I Learned,” Vox, December 18, 2018, vox.com/health-care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america.
23. R. Bichell, “A Hospital Charged $700 for Each Push of Medicine Through Her IV,” National Public Radio, June 28, 2021, npr.org/sections/health-shots/2021/06/28/1007198777/a-hospital-charged-more-than-700-for-each-push-of-medicine-through-her-iv.
24. R. Derlet, R. McNamara, and C. Tomaszewski, “Corporate Control of Emergency Departments: Dangers from the Growing Monster,” Journal of Emergency Medicine 62, no. 5 (May 2022): 675–84.
25. Derlet, McNamara, and Tomaszewski, “Corporate Control.”
26. Derlet, Corporatizing American Health Care.
27. J. Hancock, “Hospital ‘Trauma Centers’ Charge Enormous Fees to Treat Minor Injuries and Send People Home,” KHN, Kaiser Family Foundation, July 16, 2021, khn.org/news/article/hospital-trauma-centers-charge-enormous-fees-to-treat-minor-injuries-and-send-people-home.
28. Derlet, Corporatizing American Health Care.
29. R. Derlet and M. Borden, “EPs Are the New Servants for Corporate America,” Emergency Medicine News 44, no. 6 (June 2022): 2–3; and B. Wolfson, “ER Doctors Call Private Equity Staffing Practices Illegal and Seek to Ban Them,” KHN, Kaiser Family Foundation, December 22, 2022, khn.org/news/article/er-doctors-call-private-equity-staffing-practices-illegal-and-seek-to-ban-them.
30. Derlet, Corporatizing American Health Care.
31. Consumer Reports, “Why Is Healthcare So Expensive?”; D. Wainer, “CVS Has Little Time to Waste as Amazon, Walgreens Ink Doctor Deals,” Wall Street Journal, November 10, 2022; and B. Japsen, “CVS Beats Amazon and Rivals for Signify Health with Winning $8 Billion Bid,” Forbes, September 5, 2022, forbes.com/sites/brucejapsen/2022/09/05/cvs-health-bests-amazon-rivals-for-signify-health-with-8-billion-bid/?sh=59a6c7571cbd.
32. N. O’Neill, “Recognizing the Importance of Whistleblowers in Healthcare,” Nursing 51, no. 4 (April 2021): 54–56; G. Morgenson, “Doctor Fired from ER Warns About Effect of For-Profit Firms on U.S. Health Care,” NBC News, March 28, 2022, nbcnews.com/health/health-care/doctor-fired-er-warns-effect-profit-firms-us-health-care-rcna19975; Derlet, McNamara, and Tomaszewski, “Corporate Control”; and N. Scheiber and B. Rosenthal, “Nurses and Doctors Speaking Out on Safety Now Risk Their Job,” New York Times, April 27, 2020, nytimes.com/2020/04/09/business/coronavirus-health-workers-speak-out.html.
33. R. Judd, “ER Doctor Who Criticized Bellingham Hospital’s Coronavirus Protections Has Been Fired,” Seattle Times, August 2, 2020, seattletimes.com/seattle-news/health/er-doctor-who-criticized-bellingham-hospitals-coronavirus-protections-has-been-fired.
34. J. Lee, “These Healthcare Workers Say They Were Fired After Raising Safety Concerns,” NBC News, February 6, 2022, nbcnews.com/news/us-news/health-care-workers-say-fired-raising-safety-concerns-rcna14710.
35. US Bureau of Labor Statistics, “Injuries, Illnesses, and Fatalities: Fact Sheet; Workplace Violence in Healthcare, 2018,” US Department of Labor, April 2020, bls.gov/iif/factsheets/workplace-violence-healthcare-2018.htm.
36. K. Milani and D. Duffy, “Profit Over Patients: How the Rules of Our Economy Encourage the Pharmaceutical Industry’s Extractive Behavior,” Roosevelt Institute, February 2019, rooseveltinstitute.org/wp-content/uploads/2020/07/RI_Profit-Over-Patients_brief_201902.pdf; J. Morgan and S. Sterling, Lowering Drug Prices: A Blueprint for Reform (New York: Great Democracy Initiative, Roosevelt Institute, November 2019); and J. Morgan and D. Duffy, “The Cost of Capture: How the Pharmaceutical Industry Has Corrupted Policymakers and Harmed Patients,” Roosevelt Institute, May 2019, rooseveltinstitute.org/wp-content/uploads/2020/07/RI_Pharma_Cost-of-Capture_brief_201905.pdf.
37. A. Allen, “$38,398 for a Single Shot of a Very Old Cancer Drug,” KHN, Kaiser Family Foundation, October 26, 2022, khn.org/news/article/bill-of-the-month-shot-prostate-cancer-drug-testosterone.
38. D. Omdahl, “Diabetic Beneficiaries Will Pay No More Than $35 for Insulin in 2023,” Forbes, October 10, 2022, forbes.com/sites/dianeomdahl/2022/10/20/diabetic-beneficiaries-will-pay-no-more-than-35-for-insulin-in-2023/?sh=103e206f3b3f.
39. J. Choi, “Why Insulin Prices Are Troublingly High,” The Hill, March 31, 2022, thehill.com/policy/healthcare/600450-why-insulin-prices-are-troublingly-high.
40. P. Bach and M. Trusheim, “Drugs at the Heart of Our Pricing Crisis,” op-ed, New York Times, March 15, 2021, nytimes.com/2021/03/15/opinion/how-to-control-drug-prices.html.
41. GoodRx, “Humira: Adalimumab,” goodrx.com/humira.
42. H. Brueck, “US Patients Can Spend More Than $3,000 per Pen for the Exact Same Life-Changing Arthritis Drug That People in Some European Countries Get for Free,” Insider, November 7, 2022, insider.com/us-patients-spending-more-on-drugs-europe-patent-thickets-humira-2022-10.
43. T. Brennan, “Pharmaceutical Marketing Revisited―United States v. Biogen Idec,” New England Journal of Medicine 387, no. 18 (November 2022): 1631–33; and Justice News, “Biogen Inc. Agrees to Pay $900 Million to Settle Allegations Related to Improper Physician Payments,” press release, US Department of Justice, September 26, 2022, justice.gov/opa/pr/biogen-inc-agrees-pay-900-million-settle-allegations-related-improper-physician-payments.
44. Gunja, Gumas, and Williams, U.S. Health Care.
45. Derlet, Corporatizing American Health Care.
46. M. FitzGerald, M. Gunja, and R. Tikkanen, “Primary Care in High-Income Countries: How the United States Compares,” Commonwealth Fund, March 15, 2022, commonwealthfund.org/publications/issue-briefs/2022/mar/primary-care-high-income-countries-how-united-states-compares.
47. T. Waldrop, The Truth on Wait Times in Universal Coverage Systems (Washington, DC: Center for American Progress, October 18, 2019), americanprogress.org/article/truth-wait-times-universal-coverage-systems.
48. B. Burgis, “The Many Bad Arguments Against Medicare for All,” Current Affairs, January 23, 2020, currentaffairs.org/2020/01/the-many-bad-arguments-against-medicare-for-all; and American Public Health Association, “Adopting a Single-Payer Health System,” policy no. 20219, October 26, 2021, apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2022/01/07/adopting-a-single-payer-health-system.
49. C. Scott, “European Countries Don’t Ration Healthcare, but We Do,” Healthline, April 5, 2019, healthline.com/health-news/european-countries-dont-ration-healthcare-we-do-110214.
50. Derlet, Corporatizing American Health Care; and E. Schneider et al., Mirror, Mirror 2021: Reflecting Poorly; Health Care in the U.S. Compared to Other High-Income Countries (New York: Commonwealth Fund, August 2021), commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly.
51. Derlet, Corporatizing American Health Care.
52. J. Henley et al., “‘A Ticking Time Bomb’: Healthcare Under Threat Across Western Europe,” The Guardian, December 14, 2022, theguardian.com/society/2022/dec/14/a-ticking-time-bomb-healthcare-under-threat-across-western-europe.
53. Open Secrets, “Industry Profile: Hospitals/Nursing Homes,” opensecrets.org/federal-lobbying/industries/summary?cycle=2021&id=H02.
54. Open Secrets, “Industry Profile: Pharmaceuticals/Health Products,” opensecrets.org/federal-lobbying/industries/summary?cycle=2021&id=H04.
55. Congressional Research Service, “Health Provisions of the Inflation Reduction Act,” September 1, 2022, crsreports.congress.gov/product/pdf/IF/IF12203.
56. A. Ollstein, “‘The Slippery Slope Is Powerful’: Dems Believe Drug Pricing Law Will Pay Dividends,” Politico, December 29, 2022, politico.com/news/2022/12/29/democrats-drug-pricing-medicare-00075246.
57. Derlet, Corporatizing American Health Care.
58. Centers for Medicare and Medicaid Services, “No Surprises: Understand Your Rights Against Surprise Medical Bills,” January 3, 2022.
[Illustrations by Nate Kitch]