Category: health care

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    Join us for an upcoming live virtual event, “How to Use ProPublica’s Updated ‘Nursing Home Inspect’ Database.”

    ProPublica has updated “Nursing Home Inspect,” our database that helps you find problems that inspectors identified in more than 15,000 U.S. nursing homes, to make it easier to search government reports and browse serious issues. We’ve added new data, a redesigned user interface and advanced search features.

    We have expanded the database’s search capabilities, adding advanced search features that allow users to search reports in multiple states or territories, filter by type of inspection report, focus on inspections within a date range, and look specifically at reports with certain kinds of issues, also called “deficiencies.” These filters will allow journalists and others to quickly identify problematic homes in their searches, and will make it easier for curious researchers to ask advanced questions of the data.

    Our new advanced text search features allow users to search for multiple terms simultaneously by separating terms using AND or OR or to search for exact phrases by putting terms in quotation marks. The search also allows users to search for a word like “elope” and automatically see results for other forms of the word, like “elopement” and “eloping.” For more information, please read our guide on how to use nursing home inspect.

    To aid local journalists and others, we’ve added a section to each state or territory’s page highlighting serious deficiencies found in that location, allowing users to quickly identify homes that were recently cited for putting residents in immediate jeopardy. We’ve also added pages where you can see all nursing homes in a given county.

    The database now also includes information on how many hours, on average, a registered nurse spends with residents and on nursing staff turnover, both of which experts say are indicators of the quality of care in a home. Pages for individual homes now show flags indicating whether the home’s ownership has changed in the last 12 months, whether the home is behind schedule on government inspections, and whether the staff’s COVID-19 vaccination rates are low relative to other homes.

    In addition, we now have an expanded view of inspection reports that allows users to see detailed information about each deficiency, including its scope and severity, category and description.

    ProPublica plans to continue enhancing “Nursing Home Inspect” with new data and features in the coming months. If you write a story using this new information, come across bugs or issues, or have ideas for improvements, please let us know!

    This post was originally published on Articles and Investigations – ProPublica.

  • At least once a day Dr. Ximena Lopez sees a parent crying in her clinic. They’re crying because Lopez just told them they need to find a new way to get transition-related care for their children — by leaving Texas or sourcing treatments outside the state — because the state outlawed these treatments for trans youth. After a yearslong barrage by activists and lawmakers, the state has won the battle…

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    This post was originally published on Latest – Truthout.

  • Abortion access was already a near impossibility for people receiving services through the Indian Health Service (IHS), even before the Supreme Court overturned Roe v. Wade in Dobbs v. Jackson Women’s Health Organization. The ruling is likely to increase already high rates of pregnancy-related mortality for Native pregnancy-capable people (NPCP) in the U.S., creating “the perfect environment for…

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    This post was originally published on Latest – Truthout.

  • The Medicaid purge that began earlier this year after Congress agreed to end pandemic-era coverage requirements has now impacted more than 2.1 million people across the United States. According to KFF’s new analysis of the latest publicly available state data, at least 2,181,000 people in 30 states and Washington, D.C. have been removed from Medicaid since large-scale disenrollments started in…

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    This post was originally published on Latest – Truthout.

  • It has been more than one year since the United States Supreme Court, in a controversial decision not supported by a majority of Americans, overturned Roe v. Wade, returning authority over abortion’s legality to the states. Since the decision in Dobbs v. Jackson Women’s Health Organization, 14 states have prohibited abortion and another six have added restrictions on this basic component of…

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    This post was originally published on Latest – Truthout.

  • It has been more than one year since the United States Supreme Court, in a controversial decision not supported by a majority of Americans, overturned Roe v. Wade, returning authority over abortion’s legality to the states. Since the decision in Dobbs v. Jackson Women’s Health Organization, 14 states have prohibited abortion and another six have added restrictions on this basic component of…

    Source

    This post was originally published on Latest – Truthout.

  • The marked disruption that characterized the initial years of COVID-19, while distressing and destructive, also bore with it some radical implications. Jarred out of the course of our everyday lives, it seemed as if we might reexamine our assumptions and perhaps demand that the limited state assistance on offer continue, or even grow? So it had seemed, but those possibilities were soon foreclosed.

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    This post was originally published on Latest – Truthout.

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    It’s one of the most crucial questions people have when deciding which health plan to choose: If my doctor orders a test or treatment, will my insurer refuse to pay for it?

    After all, an insurance company that routinely rejects recommended care could damage both your health and your finances. The question becomes ever more pressing as many working Americans see their premiums rise as their benefits shrink.

    Yet, how often insurance companies say no is a closely held secret. There’s nowhere that a consumer or an employer can go to look up all insurers’ denial rates — let alone whether a particular company is likely to decline to pay for procedures or drugs that its plans appear to cover.

    The lack of transparency is especially galling because state and federal regulators have the power to fix it, but haven’t.

    ProPublica, in collaboration with The Capitol Forum, has been examining the hidden world of insurance denials. A previous story detailed how one of the nation’s largest insurers flagged expensive claims for special scrutiny; a second story showed how a different top insurer used a computer program to bulk-deny claims for some common procedures with little or no review.

    The findings revealed how little consumers know about the way their claims are reviewed — and denied — by the insurers they pay to cover their medical costs.

    When ProPublica set out to find information on insurers’ denial rates, we hit a confounding series of roadblocks.

    In 2010, federal regulators were granted expansive authority through the Affordable Care Act to require that insurers provide information on their denials. This data could have meant a sea change in transparency for consumers. But more than a decade later, the federal government has collected only a fraction of what it’s entitled to. And what information it has released, experts say, is so crude, inconsistent and confusing that it’s essentially meaningless.

    The national group for state insurance commissioners gathers a more detailed, reliable trove of information. Yet, even though commissioners’ primary duty is to protect consumers, they withhold nearly all of these details from the public. ProPublica requested the data from every state’s insurance department, but none provided it.

    Two states collect their own information on denials and make it public, but their data covers only a tiny subset of health plans serving a small number of people.

    The minuscule amount of details available about denials robs consumers of a vital tool for comparing health plans.

    “This is life and death for people: If your insurance won’t cover the care you need, you could die,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation who has written repeatedly about the issue. “It’s all knowable. It’s known to the insurers, but it is not known to us.”

    The main trade groups for health insurance companies, AHIP (formerly known as America’s Health Insurance Plans) and the Blue Cross Blue Shield Association, say the industry supports transparency and complies with government disclosure requirements. Yet the groups have often argued against expanding this reporting, saying the burdens it would impose on insurance companies would outweigh the benefits for consumers.

    “Denial rates are not directly comparable from one health plan to another and could lead consumers to make inaccurate conclusions on the robustness of the health plan,” Kelly Parsons, director of media relations for the Blue Cross Blue Shield Association, said in an email.

    The trade groups stress that a substantial majority of patient claims are approved and that there can be good reasons — including errors and incomplete information from doctors — for some to be denied.

    “More abstract data about percentages of claims that are approved or denied have no context and are not a reliable indicator of quality — it doesn’t address why a claim was or was not approved, what happened after the claim was not approved the first time, or how a patient or their doctor can help ensure a claim will be approved,” AHIP spokesperson Kristine Grow said in a written response to questions from ProPublica. “Americans deserve information and data that has relevance to their own personal health and circumstances.”

    The limited government data available suggests that, overall, insurers deny between 10% and 20% of the claims they receive. Aggregate numbers, however, shed no light on how denial rates may vary from plan to plan or across types of medical services.

    Some advocates say insurers have a good reason to dodge transparency. Refusing payment for medical care and drugs has become a staple of their business model, in part because they know customers appeal less than 1% of denials, said Wendell Potter, who oversaw Cigna’s communications team for more than a decade before leaving the industry in 2008 to become a consumer advocate.

    “That’s money left on the table that the insurers keep,” he said.

    At least one insurer disputes this. Potter’s former employer, Cigna, said in an email that his “unsubstantiated opinions” don’t reflect the company’s business model. In a separate written statement, Cigna said it passes on the money it saves “by lowering the cost of health care services and reducing wasteful spending” to the employers who hire it to administer their plans or insure their workers.

    The few morsels insurers have served up on denials stand in stark contrast to the avalanche of information they’ve divulged in recent years on other fronts, often in response to government mandates. Starting last year, for example, insurers began disclosing the prices they’ve negotiated to pay medical providers for most services.

    Experts say it’ll take similar mandates to make insurers cough up information on denials, in part because they fear plans with low denial rates would be a magnet for people who are already ailing.

    “Health plans would never do that voluntarily, would give you what their claim denial rates are, because they don’t want to attract sicker people,” said Mila Kofman, who leads the District of Columbia’s Affordable Care Act exchange and previously served as Maine’s superintendent of insurance.

    About 85% of people with insurance who responded to a recent Kaiser Family Foundation survey said they want regulators to compel insurers to disclose how often they deny claims. Pollitz, who co-authored a report on the survey, is a cancer survivor who vividly recalls her own experiences with insurance denials.

    “Sometimes it would just make me cry when insurance would deny a claim,” she said. “It was like, ‘I can’t deal with this now, I’m throwing up, I just can’t deal with this.’”

    Karen Pollitz, a senior fellow at the Kaiser Family Foundation, has written repeatedly about the lack of data on how often insurance companies deny claims. (Alyssa Schukar, special to ProPublica)

    She should have been able to learn how her plan handled claims for cancer treatment compared with other insurers, she said.

    “There could be much more accountability.”

    In September 2009, amid a roiling national debate over health care, the California Nurses Association made a startling announcement: Three of the state’s six largest health insurers had each denied 30% or more of the claims submitted to them in the first half of the year.

    California insurers instantly said the figures were misleading, inflated by claims submitted in error or for patients ineligible for coverage.

    But beyond the unexpectedly high numbers, the real surprise was that the nurses association was able to figure out the plans’ denial rates at all, by using information researchers found on the California Department of Managed Health Care’s website.

    At the time, no other state or federal regulatory agency was collecting or publishing details about how often private insurers denied claims, a 2009 report by the Center for American Progress found.

    The Affordable Care Act, passed the following year, was a game changer when it came to policing insurers and pushing them to be more transparent.

    The law took aim at insurers’ practice of excluding people with preexisting conditions, the most flagrant type of denial, and required companies offering plans on the marketplaces created under the law to disclose their prices and detail their benefits.

    A less-noticed section of the law demanded transparency from a much broader group of insurers about how many claims they turned down, and it put the Department of Health and Human Services in charge of making this information public. The disclosure requirements applied not only to health plans sold on the new marketplaces but also to the employer plans that cover most Americans.

    The law’s proponents in the Obama administration said they envisioned a flow of accurate, timely information that would empower consumers and help regulators spot problematic insurers or practices.

    That’s not what happened.

    The federal government didn’t start publishing data until 2017 and thus far has only demanded numbers for plans on the federal marketplace known as Healthcare.gov. About 12 million people get coverage from such plans — less than 10% of those with private insurance. Federal regulators say they eventually intend to compel health plans outside the Obamacare exchanges to release details about denials, but so far have made no move to do so.

    Within the limited universe of Healthcare.gov, Kaiser Family Foundation’s analyses show that insurers, on average, deny almost 1 in 5 claims and that each year some reject more than 1 in 3.

    But there are red flags that suggest insurers may not be reporting their figures consistently. Companies’ denial rates vary more than would be expected, ranging from as low as 2% to as high as almost 50%. Plans’ denial rates often fluctuate dramatically from year to year. A gold-level plan from Oscar Insurance Company of Florida rejected 66% of payment requests in 2020, then turned down just 7% in 2021. That insurer’s parent company, Oscar Health, was co-founded by Joshua Kushner, the younger brother of former President Donald Trump’s son-in-law Jared Kushner.

    An Oscar Health spokesperson said in an email that the 2020 results weren’t a fair reflection of the company’s business “for a variety of reasons,” but wouldn’t say why. “We closely monitor our overall denial rates and they have remained comfortably below 20% over the last few years, including the 2020-2021 time period,” the spokesperson wrote.

    Experts say they can’t tell if insurers with higher denial rates are counting differently or are genuinely more likely to leave customers without care or stuck with big bills.

    “It’s not standardized, it’s not audited, it’s not really meaningful,” Peter Lee, the founding executive director of California’s state marketplace, said of the federal government’s information. Data, he added, “should be actionable. This is not by any means right now.”

    Officials at the Centers for Medicare & Medicaid Services, which collects the denial numbers for the federal government, say they’re doing more to validate them and improve their quality. It’s notable, though, that the agency doesn’t use this data to scrutinize or take action against outliers.

    “They’re not using it for anything,” Pollitz said.

    Pollitz has co-authored four reports that call out the data’s shortcomings. An upshot of all of them: Much of what consumers would most want to know is missing.

    The federal government provides numbers on insurers’ denials of claims for services from what the industry calls “in-network” medical providers, those who have contracts with the insurer. But it doesn’t include claims for care outside those networks. Patients often shoulder more costs for out-of-network services, ramping up the import of these denials.

    In recent years, doctors and patients have complained bitterly that insurers are requiring them to get approval in advance for an increasing array of services, causing delays and, in some instances, harm. The government, however, hasn’t compelled insurers to reveal how many requests for prior authorization they get or what percent they deny.

    These and other specifics — particularly about which procedures and treatments insurers reject most — would be necessary to turn the government’s data into a viable tool to help consumers choose health plans, said Eric Ellsworth, the director of health data strategy at Consumers’ Checkbook, which designs such tools.

    A spokesperson for CMS said that, starting in plan year 2024, the agency will require insurers offering federal marketplace plans to submit a few more numbers, including on out-of-network claims, but there’s no timeline yet for much of what advocates say is necessary.

    Another effort, launched by a different set of federal regulators, illustrates the resistance that government officials encounter when they consider demanding more.

    The U.S. Department of Labor regulates upwards of 2 million health plans, including many in which employers pay directly for workers’ health care coverage rather than buying it from insurance companies. Roughly two-thirds of American workers with insurance depend on such plans, according to the Kaiser Family Foundation.

    In July 2016, an arm of the Labor Department proposed rules requiring these plans to reveal a laundry list of never-before-disclosed information, including how many claims they turned down.

    In addition, the agency said it was considering whether to demand the dollar amount of what the denied care cost, as well as a breakdown of the reasons why plans turned down claims or denied behavioral health services.

    The disclosures were necessary to “remedy the current failure to collect data about a large sector of the health plan market,” as well as to satisfy mandates in the Affordable Care Act and provide critical information for agency oversight, a Labor Department factsheet said.

    Trade groups for employers, including retailers and the construction industry, immediately pushed back.

    The U.S. Chamber of Commerce said complying with the proposal would take an amount of work not justified by “the limited gains in transparency and enforcement ability.” The powerful business group made it sound like having to make the disclosures could spark insurance Armageddon: Employers might cut back benefits or “eliminate health and welfare benefits altogether.”

    Trade groups for health insurance companies, which often act as administrators for employers that pay directly for workers’ health care, joined with business groups to blast the proposal. The Blue Cross Blue Shield Association called the mandated disclosures “burdensome and expensive.” AHIP questioned whether the Labor Department had the legal authority to collect the data and urged the agency to withdraw the idea “in its entirety.”

    The proposal also drew opposition from another, less expected quarter: unions. Under some collective bargaining agreements, unions co-sponsor members’ health plans and would have been on the hook for the new reporting requirements, too. The AFL-CIO argued the requirements created a higher standard of disclosure for plans overseen by the Labor Department. To be fair and avoid confusion, the group said, the Labor Department should put its rules on ice until federal health regulators adopted equivalent ones for plans this proposal didn’t cover.

    That left the transparency push without political champions on the left or the right, former Assistant Secretary of Labor Phyllis Borzi, who ran the part of the agency that tried to compel more disclosure, said in a recent interview.

    “When you’re up against a united front from the industry, the business community and labor, it’s really hard to make a difference,” she said.

    By the time the Labor Department stopped accepting feedback, Donald Trump had been elected president.

    One trade association for large employers pointed out that the Affordable Care Act, which partly drove the new rules, was “a law that the incoming Administration and the incoming leadership of the 115th Congress have vowed to repeal, delay, dismantle, and otherwise not enforce.”

    The law managed to survive the Trump administration, but the Labor Department’s transparency push didn’t. The agency withdrew its proposal in September 2019.

    A Labor Department spokesperson said the Biden administration has no immediate plan to revive it.

    Ultimately, it’s the National Association of Insurance Commissioners, a group for the top elected or appointed state insurance regulators, that has assembled the most robust details about insurance denials.

    The association’s data encompasses more plans than the federal information, is more consistent and captures more specifics, including numbers of out-of-network denials, information about prior authorizations and denial rates for pharmacy claims. All states except New York and North Dakota participate.

    Yet, consumers get almost no access. The commissioners’ association only publishes national aggregate statistics, keeping the rest of its cache secret.

    When ProPublica requested the detailed data from each state’s insurance department, none would hand it over. More than 30 states said insurers had submitted the information under the authority commissioners are granted to examine insurers’ conduct. And under their states’ codes, they said, examination materials must be kept confidential.

    The commissioners association said state insurance regulators use the information to compare companies, flag outliers and track trends.

    Birny Birnbaum, a longtime insurance watchdog who serves on the group’s panel of consumer representatives, said the association’s approach reflects how state insurance regulators have been captured by the insurance industry’s demands for secrecy.

    “Many seem to view their roles as protectors of industry information, as opposed to enforcers of public information laws,” Birnbaum said in an email.

    Connecticut and Vermont compile their own figures and make them publicly accessible. Connecticut began reporting information on denials first, adding these numbers to its annual insurer report card in 2011.

    Vermont demands more details, requiring insurers that cover more than 2,000 Vermonters to publicly release prior authorization and prescription drug information that is similar to what the state insurance commissioners collect. Perhaps most usefully, insurers have to separate claims denied because of administrative problems — many of which will be resubmitted and paid — from denials that have “member impact.” These involve services rejected on medical grounds or because they are contractually excluded.

    Mike Fisher, Vermont’s state health care advocate, said there’s little indication consumers or employers are using the state’s information, but he still thinks the prospect of public scrutiny may have affected insurers’ practices. The most recent data shows Vermont plans had denial rates between 7.7% and 10.26%, considerably lower than the average for plans on Healthcare.gov.

    “I suspect that’s not a coincidence,” Fisher said. “Shining a light on things helps.”

    Despite persistent complaints from insurers that Vermont’s requirements are time-consuming and expensive, no insurers have left the state over it. “Certainly not,” said Sebastian Arduengo, who oversees the reporting for the Vermont Department of Financial Regulation.

    In California, once considered the most transparent state, the Department of Managed Health Care in 2011 stopped requiring insurance carriers to specify how many claims they rejected.

    A department spokesperson said in an email that the agency follows the requirements in state law, and the law doesn’t require health plans to disclose denials.

    The state posts reports that flag some plans for failing to pay claims fairly and on time. Consumers can use those to calculate bare-bones denial rates for some insurers, but for others, you’d have to file a public records request to get the details needed to do the math.

    Despite the struggles of the last 15 years, Pollitz hasn’t given up hope that one day there will be enough public information to rank insurers by their denial rates and compare how reliably they provide different services, from behavioral health to emergency care.

    “There’s a name and shame function that is possible here,” she said. “It holds some real potential for getting plans to clean up their acts.”

    Kirsten Berg contributed research. David Armstrong and Patrick Rucker contributed reporting.

    This post was originally published on Articles and Investigations – ProPublica.

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    The organization that governs U.S. organ transplant policies voted unanimously on Monday to require that donors be tested for a parasitic disease called Chagas.

    Last week, ProPublica reported on the death of Bob Naedele, a former police detective from Connecticut who died in 2018 after receiving an infected heart; his death could have been prevented if the donor had been tested for Chagas. The policy change comes after years of recommendations from experts for screening to prevent such deaths.

    The new policy, passed by board members of the Organ Procurement and Transplantation Network, will require the groups that recover organs in the U.S. to test the blood of donors born in countries where Chagas disease is prevalent, including Mexico and 20 nations in South and Central America. To be implemented, the policy will need to be approved by the federal Office of Management and Budget.

    “My family and I are elated hearing about the policy change,” said Cheryl Naedele, Bob’s wife. “Ensuring no heart recipient will ever have to suffer the ravages of Chagas has been our passion since Bob’s passing.”

    Test results will not have to be provided to patients and their medical team before transplant. That means that patients potentially could find out after their transplant that they had received an infected organ — and not have a chance to weigh the risks of a worse outcome.

    The Organ Procurement and Transplantation Network committee that drafted the proposal originally planned to require testing to be completed before a transplant. But “many commenters were concerned that the lack of availability of testing and time it takes to get test results could lead to” delays or wasted organs, spokesperson Anne Paschke said, so the committee removed the pre-transplant requirement.

    Experts said that any testing requirement can still improve outcomes even if results arrive after a transplant because medical teams could begin treating an infection promptly, rather than discovering the disease after symptoms appear. Treatment for Chagas disease is available, but it’s not always successful in transplant recipients because their immune system needs to be suppressed so their body will not reject the new organ.

    In Bob Naedele’s case, his diagnosis took weeks and came too late, after the parasite had invaded his nervous system and brain. He died seven months after what had initially appeared to be a successful transplant.

    This post was originally published on Articles and Investigations – ProPublica.

  • Comedian Dulcé Sloan took to Twitter recently with a burning health question: “Soooo EVERY black woman has fibroids,” she wrote, injecting a bit of hyperbole, “and no one knows why?!” The tweet sparked a flurry of responses theorizing why 80% of Black women develop abnormal, noncancerous growths in their uteruses by age 50. Black women also experience fibroids at earlier ages than white women and…

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  • In a concerning turn of events, Ohio has become the newest addition to the growing list of states progressing gender affirming care bans for transgender youth out of legislative committees. If Ohio successfully passes this bill, House Bill 68, it will become the 20th state to do so. The bill has weathered numerous iterations and significant setbacks in the past. However, the latest version has…

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  • New data shows that the number of legal abortions plummeted by the thousands in states that banned abortion after the Supreme Court struck down Roe v. Wade last year, demonstrating the vast chilling effect that bans have had on people’s ability to access the procedure. According to data from #WeCount analyzed by FiveThirtyEight, states that had an abortion ban in place for at least one week…

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  • A healthcare catastrophe is unfolding across the U.S. as states — now unrestrained by coverage rules enacted early in the coronavirus pandemic — continue to remove people from Medicaid at an alarming clip, mostly for procedural reasons unrelated to their eligibility for the program. The Kaiser Family Foundation (KFF), which has been tracking Medicaid disenrollments since Congress and the Biden…

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  • The American health insurance system is expensive, actively antagonizes patients, and leaves millions of people without access to coverage — and, as a new poll shows, is often dysfunctional even for the majority of people who have an insurance plan. According to a new nationally representative survey of 3,605 people with health coverage released by KFF on Thursday, roughly 6 in 10 adults with…

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    This post was originally published on Latest – Truthout.

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    This story was produced in partnership with MLK50: Justice Through Journalism and co-published with the Commercial Appeal.

    On a brisk morning in the winter of 2019, at a standing-room-only reception, a procession of speakers lavished praise on the surgeon who more than tripled the size of the liver transplant program at Methodist University Hospital in Memphis. The lifesaving doctor was receiving an honor often reserved for the dead: Methodist’s leaders announced that the hospital’s new state-of-the-art transplant center would be named for Dr. James Eason.

    Eason seemed to have reached the summit of what was then a 25-year career. A decade earlier, he had performed one of the highest-profile liver surgeries in recent history: the transplant that extended the life of Apple co-founder Steve Jobs by more than two years. That operation earned Eason the gratitude of Jobs’ widow, who later donated a total of $40 million to the transplant center he helmed and the medical school where he worked as a professor. At age 58, Eason had become one of the country’s highest-paid transplant surgeons, earning $1.7 million a year, more than anyone at Methodist but the head of its nearly 13,000-employee, six-hospital health system.

    But for all the lives the liver transplant program saved, the hospital’s leadership had growing concerns about the number of patients dying on Eason’s watch. During the five years before the renaming ceremony, those deaths had sparked investigations from the federal contractor that oversees transplant centers. They also prompted multiple health insurers to remove the liver program from their preferred networks, according to internal documents.

    In 2018, following the most recent investigation, Methodist hired a consulting firm to audit the program. The audit, conducted by peers from other transplant centers, found that numerous errors had contributed to patient deaths — and that to reduce the rate of failed liver transplants, Methodist likely would have to perform fewer transplants overall. But according to the audit, that would be difficult. Staffers felt “powerless to make change due to the resistance of leadership,” who gave the employees the impression that “volume is king,” the audit said.

    The audit concluded that “disruptive, disrespectful, non-collaborative individuals” had put the liver transplant program and its patients “in a constant state of risk.”

    In December 2018, Methodist University Hospital President Roland Cruickshank wrote a letter to the federal contractor acknowledging the transplant program’s worrisome number of deaths. “The decline in our outcomes is of the utmost concern,” he wrote, “and is not taken lightly.” Weeks later, Cruickshank sat in the front row of the renaming ceremony and stepped up to unfurl a banner with the words “James D. Eason Transplant Institute.”

    ProPublica and MLK50: Justice Through Journalism obtained an extraordinary cache of internal records that reveal Methodist leaders failed to comprehensively fix problems with the liver program before the renaming ceremony. The records include the independent audit, detailed internal reviews of patient deaths and the hospital’s correspondence with the federal contractor, a nonprofit called the United Network for Organ Sharing, or UNOS.

    One of the documents was an internal analysis drafted at Eason’s behest. In part of the analysis, one of his most senior colleagues determined that between late 2014 and mid 2018, 25 deaths — more than half of the program’s 48 total fatalities — were preventable.

    The analysis found that some liver recipients had died after their transplant as a result of “process/protocol issues.” It also found that a portion of patients “should not have been listed” for transplant due to preexisting medical conditions.

    Along with the documents, interviews with families of nearly two dozen liver transplant recipients who died over the past decade show that, in some cases, Methodist staffers didn’t tell them about the extent of the problems that contributed to their loved ones’ deaths.

    Terry Green, a retired Army noncommissioned officer who donated a portion of his liver to his identical twin brother, did not know that Eason’s team had, according to medical records and internal documents, failed to conduct enough testing to rule out the risks of cardiac and pulmonary complications before Eason himself performed the transplant. His brother died from cardiac arrest in the operating room.

    Terry Green donated a portion of his liver to his identical twin brother, Jerry Green.

    Stacy Roberts was unaware that, following her father’s transplant, Eason’s team had identified major problems with the donated liver it had placed inside him, issues it may have been able to identify with further screening, internal records show. Methodist had accepted the liver from another hospital, which had failed to spot that the organ bore the early signs of cirrhosis. Days later, after her father experienced serious complications, Methodist providers conducted their own biopsy, discovering the full extent of the damage to the organ. Her father died about a month after the surgery. Hospital records show that transplant program leaders later required surgeons to more rigorously review liver donations before accepting those organs for patients.

    For years, Tiffany Garrigus was haunted by the memory of watching her 59-year-old father die just several hours after his transplant. Unbeknownst to Garrigus, a nurse had reported concerns about internal bleeding to the surgical fellow on shift and noted that the doctor failed to quickly alert the attending surgeon. The miscommunication delayed potentially lifesaving care. The independent auditors later determined that Methodist’s own review of Steve Garrigus’ death was a “missed opportunity” to prevent similar issues in the future.

    “They screwed up,” Garrigus said after she learned about records that outlined Methodist’s treatment of her father. “No one was held accountable and nothing changed.”

    Tiffany Garrigus visits the grave of her father, Steve Garrigus, in Union City, Tennessee.

    Garrigus and five other families who spoke with ProPublica and MLK50 signed documents waiving their rights to privacy so Eason and Methodist could answer questions about their loved ones’ deaths. Eason and Methodist declined to address those questions. The hospital and Eason also did not answer specific questions about the dozens of deaths detailed in the investigations, the findings in the audit of the transplant program or the correspondence between the hospital and UNOS.

    Spokespeople for Eason and the hospital asserted that ProPublica and MLK50 singled out patients with negative outcomes. Methodist spokesperson Tabrina Davis also said in a statement that the news organizations had “settled on a clear narrative, one which we believe is a misleading and inaccurate portrayal of the institute.” The statement went on to say that “the transplant institute is on a continuous journey of improvement, focused on providing the highest quality care for each patient.”

    Eason turned down multiple requests to be interviewed for this story but responded to questions in writing at various points. In one statement, he said that he and his team at Methodist “tried to give every patient the opportunity for transplant.” He also said in that statement that while there were “2-3 unexpected deaths per year” between 2011 and 2018, “we also saved more than 100 lives each year, all of whom would have died without liver transplantation.” Eason’s lawyer, Elizabeth Sacksteder, said in a separate letter that “performing more transplants rather than fewer” and using “the best available organs rather than waiting for the perfect organ” are pivotal parts of Eason’s approach to running a liver transplant program.

    Dr. James Eason discusses Methodist’s liver transplant program with the advisory board of the University of Tennessee Health Science Center’s College of Medicine in 2015. (via University of Tennessee Health Science Center’s Facebook)

    For more than a decade, Methodist liver recipients had a greater-than-expected chance that their liver would not be functioning one year after transplant, a metric used by UNOS to assess transplant centers’ performance. Eason said in his statement that UNOS had overrelied on that metric without taking into account that programs like Methodist have accepted more high-risk patients who would otherwise die imminently. He added that Methodist has excelled at minimizing the extent to which patients die on the waitlist, a metric that is now part of how UNOS evaluates transplant programs.

    “I would never choose to let a single high-risk patient die instead of giving that individual a good chance of living,” Eason said in another statement.

    Eason, however, is no longer making those choices at Methodist. This past August — after years of investigations and years of Methodist leaders celebrating Eason’s accomplishments — hospital employees were unexpectedly pulled into a conference room at the transplant center. Standing at the front of the room, along with other top executives, was the head of the health system. He shared a brief message that caught employees off guard: Eason was no longer with the James D. Eason Transplant Institute.

    Methodist’s Liver Transplant Outcomes Drew Scrutiny From Investigators

    The United Network for Organ Sharing launched two investigations over the past decade after Methodist University Hospital’s liver transplant program performed worse than expected.

    Note: Transplant centers report data about their performance to UNOS, which along with the Scientific Registry of Transplant Recipients examines whether the performance of transplant programs was worse than expected. To do so, UNOS analyzes the extent to which transplanted livers still functioned one year after a surgery. Each percentage is based on outcomes over the prior 30-month period. For still-functioning transplants performed in the last six months of the study period, the chance of a liver continuing to function one year after the surgery is modeled after the outcomes of previous transplants in the study period. The blue line shows the percentage of Methodist patients expected to have a functioning transplanted liver at one year, based on characteristics of the liver transplant program’s prior recipients and donors. The yellow and gray lines show the chance of a patient having a functioning transplanted liver at one year, modeled after real-world outcomes. (Source: The Scientific Registry of Transplant Recipients)

    Before his arrival at Methodist, Eason led another transplant center that was investigated for its poor performance during his tenure.

    In the winter of 1998, Eason left his post as head of a San Antonio military hospital’s transplant center to begin a new job. He now oversaw liver and kidney transplants at the Ochsner Foundation Hospital just outside New Orleans. Eason’s team increased the number of liver transplants Ochsner performed from 23 in 1998 to 76 in 2001. But the rapid growth was followed by higher rates of deaths within a year of transplant, according to data from the Scientific Registry of Transplant Recipients.

    One of Eason’s colleagues, Dr. Ari Cohen, subsequently wrote in a presentation to a group of transplant experts that the rate of adult patients living for one year after their liver transplants at Ochsner became “significantly worse than expected” between July 2002 and December 2004.

    In 2005, a UNOS committee began investigating the reasons behind poor outcomes at Ochsner, according to an article written by Ochsner doctors that was later published in the health system’s academic journal. The article described the liver transplant program’s culture prior to 2005 in a way that was similar to what Methodist’s audit would turn up years later: A “feeling of fear” had left employees “unable to freely express their views” about the program’s problems.

    In response to the UNOS investigation, Ochsner put together a team that determined the transplant center’s leadership was one of the biggest problems contributing to the liver program’s poor patient outcomes.

    UNOS spokesperson Anne Paschke said that the organization does not comment on specific investigations. Cohen, along with other Ochsner doctors who contributed to the article, did not respond to emails or phone calls. An Ochsner spokesperson declined to respond to ProPublica and MLK50’s questions or make anyone available for an interview. Eason declined to comment on the UNOS investigation or his former colleagues’ reflections on the program under his leadership. In his statement, he said that he came to Ochsner after the program had been “closed due to loss of leadership” and that the program “went from saving zero lives to saving more than 80 lives each year.”

    Before the UNOS committee completed its investigation, Eason accepted an offer that would allow him to return to his home state of Tennessee — and provide an opportunity to take another small liver transplant program and grow it even more dramatically.

    In the five years following Eason’s departure, his former colleagues addressed the problems, according to the journal article. They turned Ochsner’s liver program into one of the top performers in the South, according to health care ratings organizations.

    When Methodist announced Eason’s hiring in 2006, Dr. Hosein Shokouh-Amiri was deeply concerned. The veteran Methodist surgeon said he had heard about the rapid expansion of Ochsner’s transplant program and was worried that a similar approach might lead to higher rates of failed liver transplants for Methodist patients.

    Amiri was afraid that Eason would override clinical decisions that Amiri or his colleagues had determined were in the best interest of patients. And so he decided to leave the transplant program shortly after Eason arrived. Before Amiri’s final day at Methodist, Eason wanted to know if he would reconsider. Sitting in Eason’s office, Amiri asked if Eason would ever require a surgeon to accept a donated liver that the surgeon would rather decline because of poor quality. Amiri recalled that Eason wouldn’t answer at first. Amiri said that when he pressed for an answer, Eason told him that he would do so if he felt it was necessary.

    Dr. Hosein Shokouh-Amiri, a former surgeon at Methodist, resigned because of concerns over how Eason might lead the liver transplant program.

    As Amiri saw it, Eason’s track record of boosting volume would “bypass the moral and ethical standard we had promised” to Methodist patients.

    “He wanted my approval,” Amiri said. “I resigned.”

    Eason did not respond to questions about Amiri’s recollections and concerns. Eason’s spokesperson, Stefan Friedman, wrote in an email that Amiri left Methodist “to go to a program that performed only 11 transplants last year with higher deaths on the waitlist and lower one-year survival rates.” Amiri said that his liver transplant program had lower survival rates “because we took sicker patients.” Federal health data confirms that Amiri’s program accepted a higher percentage of patients at high risk of death from liver disease than Methodist.

    During his early years in Memphis, Eason led the dramatic growth of Methodist’s liver transplant program. The year before he started, in 2005, Amiri and his colleagues had performed 34 liver transplants. Over the next three years, Eason’s team more than tripled the hospital’s annual number of liver transplants, replacing 117 organs in 2008. Methodist leaders celebrated this growth as a historic achievement — one that allowed the liver transplant program to serve more patients in a majority Black city that had a higher poverty rate than the national average. Eason’s lawyer said in a letter that the population of the Memphis region “disproportionately suffers from co-morbidities associated with poverty” that “heighten the inherent risks of liver transplant surgery.”

    By performing 126 transplants in 2009, Methodist became one of America’s 10 largest liver transplant programs. As hospitals across the country expanded their transplant centers, they stood to profit from treating more patients suffering organ failure. According to a 2009 study published in Medical Care Research and Review, the average cost of a U.S. liver transplant and the subsequent days spent recovering in the hospital was about $163,000. Around that time, The Wall Street Journal reported that some hospitals charged nearly three times as much for the surgery. Friedman said in a statement that Eason did not receive additional compensation for performing more transplants, “nor was any aspect of his compensation based on such a metric.” Methodist did not respond to questions about the program’s finances.

    The growth of Methodist’s program was fueled in part by a special agreement with federal health officials that allowed the program to obtain livers across the entire state of Tennessee and parts of Arkansas and Mississippi. As the program grew, it began attracting more patients from beyond the greater Memphis area. A central Ohio minister received a liver transplant at Methodist in 2009 after being rejected by three other programs. He lived for another 12 years. A mechanic from San Juan, Puerto Rico, who experienced liver failure received a transplant at Methodist in 2010; in an interview translated by his wife, Carlos Acevedo Martinez told ProPublica and MLK50 that he had no complications and was grateful “Methodist gave him life again.”

    Near the end of his third year at Methodist, Eason was in touch with his friend George Riley, a Memphis native whose parents had been doctors at Methodist. Riley, a California lawyer, wanted to know if Eason might help his client. Steve Jobs faced a long wait to get a new liver in his home state of California. His wife, Laurene Powell Jobs, had learned that people could be simultaneously added to waitlists in multiple states. Since Jobs had a plane, he could fly to whichever transplant center was willing to accept him. Tennessee, it turned out, had a shorter waitlist.

    One day in March 2009, before dawn, Eason waited for Jobs’ plane at the Memphis airport. “I went to meet him and escorted him to the hospital,” Eason later told WMC-TV. One of Jobs’ biographers, Walter Isaacson, wrote that Eason closely oversaw Jobs’ care after the transplant, assigned nurses solely to his recovery and “would even stop at the convenience store to get the energy drinks Jobs liked.” Jobs later recovered in a 5,784-square-foot mansion in Memphis that Riley purchased through a shell company, according to The Commercial Appeal.

    Weeks after Jobs returned home that spring, news broke of his surgery. Media outlets including CNN and The New York Times published articles that explored whether Eason gave preferential treatment to the billionaire. The surgeon pushed back: Jobs was the sickest, most deserving patient on the day that liver became available, he said. Starting that summer, Eason lived on and off in the mansion — a perk he didn’t publicly disclose at the time. Two years later, in 2011, he bought the house from the shell company for $850,000, the same price the company paid for it in 2009. (Home sale prices in the greater Memphis area had fallen in the interim.) Eason did not respond to questions about living in or buying the home.

    Eason speaks with a nurse in Methodist’s transplant ward on Aug. 18, 2009. (Lance Murphey/Bloomberg via Getty Images)

    Around the time of Jobs’ transplant, Methodist’s liver recipients had a better estimated chance of their organs functioning at least one year after a transplant than the national average. But in the years after Jobs’ surgery, Eason’s liver transplant program began to struggle. The rate of failed liver transplants increased between July 2010 and December 2012. As a result, the UNOS committee that had scrutinized Ochsner’s performance under Eason opened an investigation in early 2014. The committee’s work is confidential, but ProPublica and MLK50 obtained records that described the investigation. (UNOS declined to confirm when the investigation ended.)

    The UNOS committee, which is composed of several dozen transplant experts who volunteer to review their peers’ programs, can recommend the discipline of transplant centers for their poor performance. But the committee rarely punished programs. In fact, the committee was so toothless that in 2018 the then-CEO of UNOS likened the committee’s investigations to “putting your kids’ artwork up at home.”

    “You value it because of how it was created rather than whether it’s well done,” the UNOS leader wrote of the investigative committee. “Only in this case, we persuade ourselves that it’s well done anyway.”

    Though Eason now defends the program he led, he acknowledged in an April 2014 letter to the UNOS committee that Methodist’s outcomes “were not as expected.” He pledged to address the committee’s concerns.

    According to internal documents from June 2014, Methodist was anticipating potential financial fallout from those poor outcomes. A Centers for Medicare & Medicaid Services official had informed Methodist that its liver transplant program was out of compliance with federal standards because it had “significantly lower than expected” outcomes and did not have an adequate policy for evaluating the reasons behind its failed liver transplants. The official warned that CMS would terminate the liver program’s participation in Medicare, which covered the costs for nearly a third of the liver transplants performed at Methodist, if it failed to correct those problems.

    In its written plan outlining how it would fix the problems, Methodist told CMS that one way it would improve outcomes was through Eason encouraging a “higher scrutiny of patients” whose risks of complications outweighed the potential benefits of surgery. Methodist ultimately avoided termination from Medicare.

    But records obtained by ProPublica and MLK50 show that Methodist kept accepting patients whose poor health increased the risk of complications after a transplant. Eason’s team soon approved for transplant a 356-pound woman with a BMI of 66 and a woman who struggled so much with drinking alcohol that she only stopped after getting sick from liver failure. The team also signed off on a patient for transplant in spite of the fact that she was septic the day before the surgery. All three died within a year after their transplants.

    Dr. Satheesh Nair, one of Eason’s most senior colleagues, later determined in an analysis of patient deaths that Methodist should not have placed these patients on the transplant waitlist. Nair did not respond to questions. Eason did not comment on the findings of the analysis, but said that he asked for it to be done as part of his transplant program’s efforts to improve its quality of care.

    Davis, the Methodist spokesperson, also declined to comment on Nair’s findings. She said in a statement that Methodist has turned away liver transplant candidates because they “do not meet the criteria to indicate they would have successful outcomes” after a transplant.

    By the time Jerry Green arrived at Methodist in 2016, the 46-year-old minister from West Memphis, Arkansas, was experiencing symptoms of liver failure, including fatigue and jaundice. As Green underwent a battery of tests, the evaluation revealed potential signs of pulmonary hypertension, according to hospital records. That condition can increase the risk of death from a transplant.

    Medical experts have written in journal articles that when a transplant candidate has signs of pulmonary hypertension, additional testing, including what’s known as a right heart catheterization, should be done to more precisely determine the risk of complications during or after a transplant. If the risk is too great, liver transplant programs can either reject the patient or postpone the surgery until the patient receives care to improve their health. But “no further assessments were made,” according to an internal analysis of Green’s treatment that the liver transplant program later conducted.

    Methodist doctors calculated that Green had a strong chance of surviving for three months without a transplant. But that also meant he was unlikely to get a liver from a deceased donor because he would be low on the waitlist. According to hospital records obtained by ProPublica and MLK50, Eason encouraged Green to get a transplant immediately the only way he could: by finding a living donor. Green was reluctant. But when he gave in, he asked his twin brother, Terry. He agreed.

    First image: Terry Green shares a photo of himself and Jerry with their mother. Second image: Terry and Jerry as babies.

    In the summer of 2016, as the Green family packed inside Methodist to support the twins, a surgeon sliced open Terry’s abdomen. It was one of the first living liver donor transplants ever performed at Methodist. Once they started Jerry’s surgery, his pulmonary arterial pressure rose so much that surgeons considered halting the transplant. Methodist providers gave Jerry medication that lowered his pressure. According to an operative report from a surgical fellow, Eason “had extensive discussion with his family, where they strongly hoped to undergo the surgery with any possible measures.” (Jerry’s wife, Jacqueline Green, said that she was notified about the concerns over his pressure but did not have an in-depth discussion with Eason about the risks of proceeding with the surgery.) Eventually, surgeons began replacing his liver with a segment of Terry’s.

    Once Terry woke up, Eason stopped by to check on his abdomen. The surgeon then shared the worst news of Terry’s life. Jerry’s heart had suddenly stopped. The staff tried to revive him in the operating room but could not pull him back from the brink of death. “His heart wasn’t strong enough,” Terry remembers Eason saying. “What we learned here will help others in the future.”

    After the funeral, Jacqueline met with Eason to learn more about what went wrong. As Jacqueline asked questions about Jerry’s death, Eason said that the liver transplant was successful. “It was just his heart” that failed, she recalled Eason saying.

    Jacqueline Green at home next to a burial flag for her husband, Jerry Green, who served in the Marines.

    The following year, Methodist enacted several new policies designed to more rigorously test patients’ cardiac and pulmonary risks ahead of a liver transplant. In the program’s internal analysis, Nair later determined that Green’s death was preventable. Jacqueline said Eason never told her about that finding.

    Not long after Jerry Green’s death, Eason and nearly two dozen colleagues gathered for a confidential meeting. A familiar problem that had dogged the program was now resurfacing.

    Four years earlier, in December 2012, CMS had announced it would cut off a crucial part of Methodist’s organ supply from central and east Tennessee. Some transplant experts praised the decision because they felt Methodist had unfairly benefited from an old policy that provided access to more high-quality organs from a large geographic area. To avoid shrinking what had become the nation’s fourth-largest liver program, Methodist accepted more livers that posed a higher risk of complications for their recipients. Eason’s transplant quality director later wrote in a document responding to the UNOS committee’s investigation that the strategy was justified as the country faced a chronic organ shortage. As the quality director explained, the additional risk was in “balance against the risk of candidate death on the waitlist.”

    At the confidential meeting, Eason and his staff focused on a case that exemplified the perils of such risk-taking. That July, Methodist had received a liver offer from a North Carolina hospital. The liver had belonged to a 34-year-old military veteran who had struggled for years with use of hard drugs and alcohol. The way that he died required that his liver be removed after his heartbeat stopped, known as a donation after circulatory death or DCD. Such donations involve an organ that has been deprived of sufficient oxygen between the time of death and the organ’s removal. As a result, these donations can elevate the risks of complications for a recipient. That year, about 6% of U.S. liver transplants involved DCD organs, according to data from the Scientific Registry of Transplant Recipients. The data also showed Eason’s team accepted DCD livers at a percentage nearly triple the national average.

    The night that Methodist received the liver offer, one of Eason’s surgeons described the donor’s history to Eugene Willard, a 61-year-old grandfather who served as the mayor of his small town of Amagon, Arkansas. Willard wanted to reject the offer, according to his daughter, Stacy Roberts. Two weeks earlier, another Methodist doctor had determined Willard would be a “suitable candidate for liver transplantation providing he loses weight,” records show. That doctor had encouraged Willard to slim down to lower his risk of complications whenever the transplant did happen. But with the offer on the table that night, the surgeon urged Willard to accept the liver, his daughter recalled. “If you don’t do it, you’re going to die,” she remembered the surgeon saying. Willard followed the surgeon’s advice and agreed to accept the organ.

    After Willard’s new liver showed signs of poor function, Methodist providers ordered another biopsy to better understand his complications. This time, they saw that the donated liver had so much scarring that the early stages of cirrhosis were present. He died about a month after the surgery.

    At the confidential meeting, the team concluded that the North Carolina hospital’s biopsy of the donated liver “may have been inadequate.” Eason’s team responded by approving a policy change that required surgeons to more rigorously examine biopsies before accepting livers. Nair’s analysis later determined that Willard’s death was preventable, citing “donor selection” issues.

    Data from the Scientific Registry of Transplant Recipients shows that Methodist continued to accept DCD livers in 2017 and 2018 at rates higher than twice the national average. Eason’s transplant quality director later explained in the response to UNOS that Methodist’s surgeons accepted more high-risk livers because they had “access to fewer local organs than the national rate,” leaving the program little other choice for saving patient lives. The quality director defended the practice as one that “represents our effort to provide care to an underresourced patient population.”

    “Most have no other opportunity or hope of transplantation,” the quality director wrote.

    Over the course of 2018, Methodist’s transplant center leaders were confronting a new round of scrutiny. After a period of improved patient outcomes following the UNOS committee’s investigation four years earlier, the liver transplant program’s failure rate had again worsened. As a result, the UNOS committee opened another investigation.

    Methodist responded with a step intended to help its struggling program. It hired the transplant consulting firm Guidry & East to conduct an audit of its liver transplant program’s operations.

    Five transplant experts — including doctors affiliated with medical schools at the University of California, San Francisco and Cornell University — traveled to Memphis in October 2018 for the two-day audit. They toured the center’s halls, interviewed employees and reviewed liver transplant records. The experts wrote a 35-page report, a final draft of which was obtained by ProPublica and MLK50, that identified a list of problems that they said contributed to patient deaths.

    Excerpt from Guidry & East’s 2018 audit of Methodist’s liver transplant program (highlights added by ProPublica)

    The audit stated that Eason’s program appeared to “maximize the number of transplants by disregarding flags” as to whether patients were suitable candidates for surgery and, according to one Methodist doctor, was “currently accepting less than ideal donor organs for transplantation.” It also determined that the program had failed to thoroughly review the causes of patient deaths in order to prevent repeat mistakes with future patients, a problem previously identified during federal inspections.

    To better protect patients, Eason would need to improve its policies in a way that would limit surgeons from operating on patients unlikely to survive long after transplant, in addition to limiting the number of high-risk organs the program accepted, the experts’ audit determined.

    The experts also flagged problems with the hospital’s oversight of its liver transplant program. The audit noted the stark “disconnect” between Eason’s team and hospital leadership. “There is a lack of transparency in what is reported,” the experts determined.

    After the audit, Methodist University Hospital President Cruickshank pledged in a letter to the UNOS committee that senior hospital leadership would “work closely” with Eason’s team to adopt Guidry & East’s recommendations. Those changes, Cruickshank said, would “once again allow us to meet the UNOS requirements and our own expectations of exceptional outcomes.” (Cruickshank, who has since left Methodist, did not respond to multiple requests for comment.)

    Eason at the transplant center renaming ceremony at Methodist University Hospital in 2019. (via Methodist Le Bonheur Healthcare’s Facebook)

    In February 2019, less than two months after Cruickshank’s letter, Eason stood at the renaming ceremony before his supporters, including Laurene Powell Jobs, an internationally known philanthropist who has donated to a wide variety of causes. (Powell Jobs’ social impact organization Emerson Collective contributes to numerous media organizations, including ProPublica and MLK50, and owns a majority stake in The Atlantic. Through a spokesperson, Powell Jobs declined to comment about her support of Eason and Methodist.) In the halls of Methodist’s new $275 million nine-story tower, a portion of which would be home to the transplant center that had received her donation, Eason and Powell Jobs posed for a photo before a wood-paneled wall lettered with the surgeon’s name on it.

    Later that month, Methodist received a letter from the chair of the UNOS committee overseeing the investigation, whose members had met to review the Guidry & East audit. The letter stated that “recent outcomes do not seem to be improving.”

    In April 2019, as Methodist was about to welcome patients to its new transplant center, Eason wrote in a letter to the UNOS committee that the liver transplant program was headed in the right direction. To address the committee’s concerns, Eason presented a detailed plan that outlined how Methodist was overhauling policies within its liver transplant program. He attached newly written guidelines that directed the program to be more stringent in accepting high-risk patients and livers. He also noted that transplant leaders were routinely holding conferences where staffers more thoroughly reviewed cases with bad outcomes, openly discussed medical mistakes and identified ways to prevent repeat errors.

    “We believe our team has made tremendous progress in improving the outcomes of our Liver Transplant Program,” Eason wrote.

    Davis, the Methodist spokesperson, said in a statement that Methodist “considered every recommendation” from Guidry & East and enacted some of those policies “right away.” Neither Eason nor Nair responded to questions about the Guidry & East report.

    After the new transplant center facility opened that spring, the liver program’s numbers did, in fact, begin to turn around. The program’s rates of failed liver transplants continually improved in 2019 and 2020. But they did not improve enough to clear the threshold that the UNOS committee typically required to close an investigation.

    In 2021, UNOS rewrote the rules for investigating transplant programs. Ian Jamieson, then the chair of the investigative committee, said that judging programs on post-transplant outcomes alone had created a “disincentive to transplantation.” To remove that barrier, UNOS leaders decided, a program would have to have far worse rates of failed liver transplants before UNOS would automatically step in to investigate.

    UNOS touted the policy as “a more holistic approach” to evaluating transplant programs, since the committee would now also consider the extent to which patients were dying on the waitlist. The changes were not universally praised: Critics worried that the policy would lead to fewer transplant programs being held accountable.

    Around the time the new UNOS policy began to take effect last year, the committee ended its investigations into numerous transplant programs, including the liver transplant program at Methodist.

    Eason and a spokesperson for Methodist said that the investigation was closed because the program’s outcomes had improved. (UNOS declined to comment on the reason.) Eason said in his statement to ProPublica and MLK50 that UNOS’ new policy was recognition that UNOS had been relying on a transplant metric that was “outdated and invalid.” He sees that decision as part of a broader shift in which federal transplant policy is falling more in line with his philosophy to offer transplants to as many people as possible.

    With outcomes improving and policy shifting, Eason seemed poised to keep leading his team at the center that bore his name. But one morning this past August, Methodist transplant center employees were unexpectedly summoned into a meeting down the hall from where the renaming ceremony had taken place. For the prior week, Eason hadn’t made his usual rounds through the halls of the transplant center. His staff even had to postpone a living donor transplant because of his absence.

    Once the seats were filled, Michael Ugwueke, the president and CEO of Methodist’s six-hospital health system, asked for everyone’s attention. He informed them that Eason was no longer with the transplant center. When staffers asked what happened, Methodist executives said they couldn’t provide any details. As part of the decision, the transplant center suspended conducting liver transplants for living donors.

    Methodist and Eason declined to answer questions about his departure. Methodist has scrubbed many mentions of Eason from its website. In the six months following Eason’s departure, he remained employed as the director of the Transplant Research Institute at the University of Tennessee Health Science Center, the medical school affiliated with Methodist. In late February, he retired from his tenured position, according to emails obtained through an open records request. UTHSC spokesperson Peggy Reisser declined to comment on the retirement.

    So far, no hospital has publicly announced that Eason will lead its transplant center. Medical board records show that he has obtained licenses in Ohio and Pennsylvania. When ProPublica and MLK50 asked about Eason’s departure and search for a new job, his lawyer, Sacksteder, responded in a letter on March 15 that he is a “highly respected” liver transplant surgeon whose name still graces the transplant center he had helmed.

    Just a few weeks later, Methodist employees noticed something had changed at the hospital. Workers had removed several signs throughout the facility. The words “James D. Eason Transplant Institute” are no longer affixed to the front of the building.

    A new sign simply reads: “Methodist Transplant Institute.”

    First image: The exterior of Methodist, showing the James D. Eason Transplant Institute sign, on Feb. 17. Second image: The exterior of Methodist, without Eason’s name sign, on April 18. (Andrea Morales for MLK50) Tell Us About Your Experience With the Organ Transplant System

    Wendi C. Thomas and Jacob Steimer, MLK50: Justice Through Journalism, and Mollie Simon, ProPublica, contributed reporting.

    Design and development by Allen Tan.

    This post was originally published on Articles and Investigations – ProPublica.

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  • This article was produced for ProPublica’s Local Reporting Network in partnership with The Maine Monitor. Sign up for Dispatches to get stories like this one as soon as they are published.

    In the mid-1990s, Maine’s lawmakers and health officials made a pivotal decision to reduce the state’s reliance on nursing homes, a move intended to redirect elderly residents toward“more homelike, less institutional” alternatives.

    The policy change, enacted in 1993 amid a severe budget crunch, helped spark a dramatic transformation of the elder care system in Maine, where 21.7% of the population is 65 or older — the highest percentage in the country.

    Between 1996 and 2022, the number of nursing home beds dropped by nearly 3,680, from a high of more than 10,000, sparing Maine the financial burden of subsidizing them. During the same period, the number of beds at what are known as residential care facilities almost doubled, jumping by more than 4,200. As a result, older Mainers and other residents with significant medical needs live in these homes. Residential care facilities in Maine resemble what are known generally as assisted living facilities.

    Although the state considers residential care facilities to be “nonmedical institutions,” an investigation by The Maine Monitor and ProPublica found that these facilities are routinely called on to provide medical care to their residents — those suffering from advanced dementia or requiring medication management for conditions such as seizures and heart disease.

    Maine’s standards for these facilities are more robust than those in some other states, long-term care advocates say. But given the significant shift of beds for seniors from nursing homes to residential care, advocates say that those regulations are inadequate and in urgent need of updating and tightening.

    A review by the Monitor and ProPublica of state inspection records underscored concerns about how these facilities are regulated. State monitoring and investigation reports revealed that of the almost 700 violations issued from 2020 to 2022, roughly 200 involved “medications and treatments.” The analysis focused on citations at many of the state’s roughly 190 largest residential care facilities, called Level IV, which serve the largest number of people.

    In May 2021, for instance, state inspectors found that one facility had administered morphine to the wrong resident. The mistake led to the resident being hospitalized and treated for a week in the intensive care unit.

    Problems with medical care also showed up in other violation categories beyond the 200 related to medication and treatment. Another facility was cited with a resident’s rights violation in May 2022 for failing to get from the pharmacy a resident’s medication for cardiac issues, nicotine cessation, pain control and seizure activity for three days. The resident became agitated about not receiving the medications and went to the hospital at their family’s request over safety concerns.

    These facilities “shouldn’t have it both ways,” said Eric Carlson, director of long-term services and support advocacy at Justice in Aging, a nonprofit legal advocacy group focused on ending poverty among seniors.

    “You can’t on one hand say: ‘Oh, we’re an alternative to nursing facilities,’” and then when something bad happens say: “‘Well, we can’t be expected to have expertise on that stuff. We’re a social facility. We’re a nonmedical model,’” Carlson said.

    While medical errors happen at even the most highly equipped facilities, Maine’s residential care facilities are not set up to handle the level of need they are currently seeing in residents, said Jess Maurer, executive director of Maine Council on Aging, a network of organizations focused on issues affecting the elderly. She said these facilities are grappling with the consequences of the state’s policy change.

    “We’re pushing people with a higher level of need than should be in assisted living into assisted living facilities because there are no alternatives,” Maurer said.

    According to a 2021 report by the Maine Health Care Association, which represents the state’s elder care facilities including nursing homes, the needs of residents in assisted housing, including residential care facilities, had increased 30% since 1998, and 47% of them suffered from dementia. By 2028, the number of Mainers over 65 is projected to increase about 45% over the decade prior. And 35,000 Mainers are projected to have Alzheimer’s in 2025.

    The Maine Department of Health and Human Services, which oversees and licenses residential care facilities, declined to comment on the calls for tighter medical standards or on the violations cited by state inspectors.

    But department spokesperson Jackie Farwell said the state is in the middle of a “major long-term care reform effort” aimed at filling the gaps in the state’s elder care system. Within the next fiscal year, the department’s statutory review of assisted housing programs is expected to “lead to the adoption of updated rules relating to the operation of” residential care facilities, among other things. She declined to elaborate whether the updated rules could include tighter medical standards.

    Brenda Gallant, Maine’s long-term care ombudsman, who is empowered by the state to receive complaints from elder care residents and investigate their facilities, said the department’s effort could offer an opportunity to review the medical standards for residential care facilities.

    “It is the right time to take a look at who we are serving and what regulatory changes need to be made based on resident need,” Gallant said.

    Martin Hunt was a highly intelligent, meticulous man who enjoyed tinkering and creating all kinds of contraptions. He fashioned cup holders to his cane, assembled a guitar and built a wooden, collapsible rolling grocery cart. He designed 3D floor plans for a house on a piece of property that one of his sisters, Tania McIntyre, owns in Dedham, Maine.

    McIntyre shares a photograph of her brother, Martin Hunt.

    But McIntyre and her older sister, Melody Leavitt, witnessed Hunt’s dementia erode his mind since he suffered a stroke in 2020. As the 68-year-old’s condition worsened, they helped him move into Woodlands Senior Living of Brewer, 10 miles from Leavitt’s house.

    Within a week, the sisters regretted the move, appalled by the quality of care that Hunt was receiving. For instance, he took about 20 medications every day for a number of ailments in addition to dementia — heart conditions, lung disease, hypertension, among others — and Woodlands’ employees made a mistake when administering them, according to the facility’s daily care notes. More broadly, the sisters worried that he was being overlooked, and that staff did not take his complaints about pain seriously.

    A couple months after he moved in, Leavitt confronted Kathleen Olsen, the facility’s administrator, about the overall quality of care. She said she was floored when Olsen told her that Woodlands is not a medical facility.

    Matthew Walters, one of the owners of the Woodlands Senior Living, which operates residential care facilities in nine communities throughout Maine, including the one in Brewer, told the news organizations that he had spoken with Olsen and that she did not recall her conversation with Leavitt. But Walters echoed her point: “She’s right. We’re not a medical facility. By definition, we’re a private nonmedical institution,” he told the Monitor and ProPublica.

    Medical facilities, such as nursing homes, are required to provide daily nursing care for injured, disabled or sick people who can only be served in a nursing facility, whereas nonmedical facilities are only required to help residents coordinate and gain access to medical care, said Farwell, the DHHS spokesperson.

    All this is why the sisters began exploring options for relocating Hunt not long after his move to Woodlands. Convinced that he needed a higher level of care, they set up an assessment for him — a step required by the state before moving to a nursing home.

    To qualify, Hunt needed to be evaluated as either requiring frequent nursing or other skilled care for a long list of medical conditions or needed to score high on a points system to show that he had severe cognitive or behavioral problems.

    On the day of Hunt’s assessment in late November, conducted via a 10-minute phone call with a registered nurse, Leavitt was there in his room, listening in as he answered the assessor’s questions: Did he need help getting dressed? (No.) Did he eat by himself? (He gave a snarky answer: “When the food is edible.”)

    At one point during the call, Hunt put the phone on speaker and placed it on his bed. When he went to pick it up later, he grabbed the TV remote instead and held it to his ear. He continued to speak into it until Leavitt walked over and replaced it with the phone.

    Leavitt said the moment felt like yet another example of Hunt’s steady decline. “It was disheartening,” she said. “You’re watching him losing his mind.”

    But the assessor wasn’t in Hunt’s room to witness the scene and eventually determined that Hunt’s needs weren’t acute enough to qualify for a nursing home placement.

    Three decades ago, the state tightened the requirement for qualifying for a nursing home placement. The policy change reflected the state’s philosophical shift away from nursing homes and toward options that allowed Mainers to “age in place” at home or in less institutionalized settings for as long as possible.

    But it was also a financial decision, aimed at reducing nursing home costs, which are covered by a mix of state and federal funds under MaineCare, the state’s version of Medicaid; the costs had doubled over five years and were the single largest component in the state’s Medicaid budget.

    The rising costs meant that the state “finally had to admit that we could no longer” sustain the number of nursing home beds it had, according to a 1994 state plan from the Bureau of Elder and Adult Services, an agency under what is now the Department of Health and Human Services.

    But the policy change received immediate pushback. Legal Services for the Elderly, a nonprofit, filed a class-action lawsuit to challenge the medical eligibility requirement, which the plaintiffs said made them no longer qualify for a nursing home placement.

    Among the plaintiffs were a 78-year-old woman who had a mild seizure disorder and rapidly worsening Alzheimer’s; a 99-year-old woman who was prone to falls, was legally blind and almost deaf and needed help with dressing, bathing, toileting and hygiene; and a 92-year-old man who needed a catheter and paid privately for nursing home services for years until his savings ran out, according to the coverage in the Bangor Daily News at the time.

    The following year, the Maine Health Care Association also issued a critical report, highlighting how the policy change was pushing people with a higher level of medical needs into residential care facilities. The situation, it wrote, was putting the pressure on these facilities to provide more medical care.

    “Many of Maine’s residential care facilities are moving quickly down that path, being driven by circumstance and department pressure to medicalize their services,” the association wrote.

    Under pressure, the state eased the medical eligibility requirement in 1996, taking Alzheimer’s and other dementias more into consideration in determining whether an individual qualifies for a nursing home placement. In light of the changes, the class-action lawsuit was dropped.

    Despite that change, experts told the Monitor and ProPublica that Maine’s medical eligibility requirement for nursing homes remained among the strictest in the country, and nursing home beds have continued to disappear since 1996.

    Residential care facilities are subject to state regulations, established in 1998, that hold them to much lower minimum staffing, nursing and physician requirements than for nursing homes. Their direct-care workers are allowed to manage twice as many residents as they are in nursing homes. A registered nurse has to make a visit only once a week to residential care facilities with 40 beds or more and even less frequently to smaller ones, while nursing homes are required to hire a director of nursing and have one nurse stationed at all times. And there is no requirement that doctors visit residents at these facilities, while nursing homes are required to have a medical director and make sure that every resident is visited by a doctor every two months.

    Regulations of assisted living facilities vary greatly across the country, and experts say it is difficult to compare across states. Some states don’t have specific minimum staffing requirements like Maine does, requiring only “staffing sufficient to meet the needs” of residents.

    But just because Maine has minimum staffing requirements doesn’t mean the standards are sufficient; resident needs have increased since they were established 25 years ago, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit that advocates for elder care residents.

    “When you have people with increasing needs, you have to ensure that those needs are being met,” she said. “There needs to be government oversight of that because in too many cases the facilities are falling short and people are experiencing real harm.”

    Travis Brennan, a Maine-based attorney who handles medical malpractice claims for Berman & Simmons, said medication mistakes can signal other problems — they may indicate that employees are being rushed, aren’t trained properly or are disregarding their foundational training.

    “When you have a medication error, it is symptomatic of the fact that a provider is taking a shortcut,” Brennan said.

    From 2020 to 2022, state inspectors issued 18 citations for missing doses and medications, seven citations for wrong doses and two citations for medications given to the wrong residents at Level IV residential facilities, a ProPublica-Monitor analysis shows.

    In October, for instance, state inspectors cited one facility for failing to promptly stock one liter of oxygen for a resident who suffered from “acute respiratory failure.” It took the facility seven days after receiving a doctor’s order to contact a pharmacy.

    Smetanka said the state can address this problem by enhancing the required training, improving quality-assurance procedures, establishing medication management as a focus for oversight and looking at the penalties when these facilities make mistakes.

    “More needs to be done in terms of oversight and accountability for ensuring that these mistakes are minimized as much as possible,” Smetanka said. “A medication error can be deadly for a resident. It could have very serious consequences. So this is not something to be taken lightly.”

    Paula Banks, a geriatric social worker who has been licensed in Maine for 30 years and runs a geriatric consulting and care management firm, said the current staff ratios are not stringent enough, particularly at the residential care facilities housing residents with cognitive problems. Under the state’s medical standards, one direct-care worker is allowed to manage 30 residents overnight, but she said that’s not reasonable when the residents suffer from dementia and may not know what time it is. “It’s impossible — those ratios,” she said.

    Angela Cole Westhoff, president and CEO of the Maine Health Care Association, wouldn’t weigh in on tightening medical standards for residential care facilities, but she said that regulations should reflect the difference between nursing homes and residential care facilities, which she said “provide varying levels of care.”

    Hunt’s sisters, Leavitt and McIntyre, are quick to acknowledge that Hunt, a divorced father of three sons whom he hasn’t seen for years, could sometimes be a difficult person to be around. And they suspect that this caused his needs to be overlooked by Woodlands’ employees.

    First image: Leavitt looks through Hunt’s paperwork from his time at Woodlands. Second image: The facility in Brewer, 10 miles from Leavitt’s house.

    The facility care notes detail numerous run-ins with the employees in which Hunt was described as aggressive, rude and insulting. He allegedly called the employees names and yelled at the cook. And he clashed with the employees over his medications.

    The sisters said Hunt had long been in charge of his own medications and didn’t trust the employees to handle his prescriptions correctly. He would ask them what they were giving him and get frustrated when they wouldn’t explain. When he got worked up, Leavitt said, the employees would ask if he was refusing the medication.

    “He was just stubborn enough. They’d say that, and he’d go, ‘Well, I guess I am,’” Leavitt said.

    “He was a challenging person to have in your care. I’m not going to make any bones about it,” McIntyre said.

    “That being said, it was their job to take care of him,” Leavitt added. “In my opinion, they really didn’t.”

    In December, Hunt did have a scare when the employees gave him medication for anxiety and sleeping problems instead of a painkiller, according to the facility care notes. The employees wrote in the facility care notes that he did not have any reactions, but they called his doctors for “advisement.”

    With the sisters’ permission, Walters, one of Woodlands’ owners, discussed Hunt’s experience in detail with the Monitor and ProPublica. He acknowledged the medication mix-up but said Woodlands’ care notes did not document Hunt’s worsening dementia or increasing complaints about back pain. He said there was no significant change in Hunt’s condition that would have alerted the employees to a possible medical emergency, up until the day he was rushed to the emergency room.

    “There’s no red flag that occurs anywhere,” Walters said.

    He also said the employees tried their best, despite Hunt’s temperament, to care for him.

    The employees “worked very hard throughout the entirety of Mr. Hunt’s residency to help make each day the best day possible for him and showed great care, consideration and compassion towards him in the face of persistent challenging and abusive behaviors,” Walters said.

    He echoed what other Maine long-term care advocates and experts said: That there are residents in residential care facilities today who would have been in nursing homes 20 years ago.

    “That doesn’t mean that those people that are in a residential care facility now shouldn’t be here and should be in a nursing home,” Walters said. “In some cases, it’s just the opposite. Those people would have been in a nursing home, but they’re equally or better served in this setting.”

    According to Hunt’s sisters, that winter, Hunt began complaining that his back pain was becoming markedly worse. Around supper time on a weekend night in February, Leavitt got a call from a Woodlands employee about Hunt: He had been found unresponsive on the floor of his room. He looked pale, his lips were blue and emergency responders couldn’t get him to squeeze their hand. He was rushed to a nearby hospital.

    The sisters braced for the worst, fearing that Hunt had suffered a second stroke in four years. “I just thought this is going to be the end of him,” McIntyre said.

    When McIntyre arrived at the hospital, she initially heard good news: Hunt’s doctors had ruled out the stroke. McIntyre said her reaction was a visible and audible sigh of relief.

    But then Hunt was soon moved to the intensive care unit after his doctors found a kidney bleed — it was near a part of his back where the sisters said he had complained about dramatically worsening back pain in the weeks before he went to the ER.

    Hunt’s doctors discussed surgery options for him, but the sisters feared that they wouldn’t succeed and he would end up with him on a ventilator — which they knew he wouldn’t want. They opted for comfort care instead.

    That night, nurses unhooked his heart monitor and gave Hunt a pump of morphine. Leavitt remembered the stress immediately disappearing from his face. When he woke up, he was starving and asked for a cheeseburger, fries and a hot coffee. The three siblings had their best visit in months.

    “You just had to wonder, was pain causing it all?” Leavitt said.

    The next morning, as the sisters were walking back down the hospital hallway to visit him again, the doctor called and told them to hurry.

    “We get in his room, and they said, ‘Martin, your sisters are here.’ And, within a couple of minutes, he took his last breath,” Leavitt said. “It’s like he waited for us or something.”

    First image: Leavitt and McIntyre in Leavitt’s home. Second image: Leavitt holds a stone heart that was left as a tribute on Martin’s chest by the nurse when he died.

    Leavitt, meanwhile, said she didn’t blame Woodlands for Hunt’s worsening dementia but held the facility responsible for not noticing the change in their brother’s dementia and pain levels that they say were obvious and for failing to take action to improve his care.

    “If they’re going to allow people like my brother to be in their facility, they should be able to care for him,” Leavitt said. “That’s what our intent was: For him to be safe and be cared for when he needed help.”

    Help Us Report on Assisted Living Facilities in Maine

    Correction

    May 22, 2023: This story originally referred imprecisely to a medication that residential care staff had incorrectly provided to Martin Hunt. He was given medication for anxiety and sleeping problems, not seizures.

    This post was originally published on Articles and Investigations – ProPublica.

  • When a federal judge in Texas declared unconstitutional a popular part of the Affordable Care Act that ensures no-cost preventive care for certain services, such as screening exams for conditions such as diabetes, hepatitis, and certain cancers, it left a lot of people with a lot of questions. On the face of it, the March 30 decision could affect ACA and job-based insurance plans nationwide and a…

    Source

    This post was originally published on Latest – Truthout.

  • The Biden administration is poised to allow the national emergency on COVID-19 to expire on May 11, 2023. Once that occurs, between 5 to 14 million Americans previously covered under Medicaid will lose their insurance. Although the pandemic continues to rage, killing thousands and infecting hundreds of thousands each week, a bipartisan consensus has settled in Washington to simply pretend COVID-19 is “over.” What meager safety net was extended at the start of the pandemic is now being rolled back—leaving Americans to shoulder the risks and expenses of illness and death entirely on their own. Dr. Margaret Flowers joins The Chris Hedges Report to discuss the toll that COVID denialism will have on our society, and the generally outrageous state of US healthcare. 

    Dr. Margaret Flowers is a pediatrician and activist for single payer healthcare. She served as co-chair of the Green Party of the United States until 2020, and is currently an adviser to the board of Physicians for a National Health Program

    Studio Production: Adam Coley, David Hebden, Cameron Granadino
    Post-Production: Adam Coley, Cameron Granadino


    Transcript

    The following is a rushed transcript and may contain errors. A proofread version will be made available as soon as possible.

    Chris Hedges:

    The National Emergency and Public Health Emergency declarations related to the COVID-19 pandemic will terminate on May 11th, 2023. These emergency declarations in place since 2020, waived or modified requirements in a range of areas, including in the Medicare, Medicaid, and chip programs, as well as in private health insurance. The end of these special measures will see between five and 14 million Americans lose their Medicaid coverage according to the Kaiser Family Foundation, more than 30 million Americans already don’t have health insurance, and millions more are under insured. Even with insurance, medical costs are so high, the medical bills are the cause of bankruptcy for half a million people a year, the number one cause of bankruptcy in the United States. The average American spends more than $12,500 per year on personal healthcare, some $4 trillion annually. A citizen in France spends $5,468, in Canada, $5,905, in Germany, $7,382 for Universal Care.

    The organization for Economic Cooperation and Development found that despite the high cost of US healthcare and nearly every critical ranking from life expectancy at birth and deaths from avoidable conditions, the US consistently ranks at the bottom. 68,000 Americans die every year because they are uninsured or underinsured. This is because the US healthcare system does not serve the public, it serves the medical insurance and drug companies whose lobbyists gut regulations and block healthcare reform.

    In 2020, the CEOs of 178 major healthcare companies collectively made 3.2 billion in total compensation, that was up 31% from 2019, all in the midst of the pandemic. According to Axios, in 2020, the CEO of Cigna took home $9 million, the CEO of Centene made $59 million, the CEO of United Health Group received $42 million in total compensation. The CEO of Moderna got a $926 million golden parachute after his company received $2.5 billion in taxpayer dollars from the Trump administration to develop its COVID vaccine.

    These huge profits were being made when over 330,000 Americans died during the pandemic because they could not afford to go to a doctor on time. Joining me to discuss the debacle that is the US Healthcare System is Dr. Margaret Flowers, an advisor to the board of Physicians for a national health program, and one of the country’s most prominent advocates for single payer health insurance. Margaret, let’s begin with how we got here, there was a proposal several decades ago, I believe it was under the Trump administration, I can’t remember, for single payer that got stopped, and then bring us up to where we are today.

    Margaret Flowers:

    There’s actually been a movement for a national health insurance for more than a hundred years now in the United States. And David Barton Smith writes beautifully about this, the movement keeps compromising just as it did in 2010 under the Affordable Care Act. But profiting off of healthcare was not legal in the United States until the 1970s under the Nixon administration with the Health Maintenance Organization Act, and there’s a tape of Nixon saying, the companies can make a lot of money off of this.

    But Reagan really took it to another level when he brought investment firms into the Department of Health and Human Services and trained them on how to take over healthcare, is what they called a fertile field for making profits. And so since that time, not only have we seen the consolidation and privatization of our healthcare system, but the public portion of our healthcare system, Medicaid and Medicare are also majority privatized now to the point where for the top five major health insurance corporations, more than half of their revenue just comes from being paid by the government for running Medicaid and Medicare. So it’s eating into those public systems that we were trying to preserve to at least have some space in our healthcare system that was about taking care of people and not making profits.

    Chris Hedges:

    Let’s go back to Obamacare. You were very involved in fighting for single payer, Obama promised that single payer universal healthcare would be an option, which under pressure from the insurance and pharmaceutical industry, he removed, it never was. But you called out, I think in retrospect you’ve been proven right, you, Kevin Zeese, and other activists. But talk about that seminal moment because it’s an important moment, and I remember hearing you speak, you knew what was coming.

    Margaret Flowers:

    It was an important moment for me personally as well. Physicians for National Health Program is based in Chicago where Obama lived, one of the leading members, he’s deceased now, but Dr. Quentin Young was in the practice that treated Obama for healthcare. And as a state Senator, Obama used to go around with Quentin Young and others saying, healthcare’s a human right, and somewhat, he was trying to give that message during the campaign.

    But then we have to recognize, I think he was one of the first presidents that received such huge amounts of money from the health insurance corporations, the pharmaceutical corporations. And so we thought we might have some seat, but it was very clear from March of that year, 2009, when he came into office, he was holding a summit at the White House and he was inviting the health insurance corporations and the pharmaceutical companies and no proponents of a single payer system. And we protested that, and finally they did let a few in, but it was really for show not substance.

    And so at every bit of that fight, we were excluded. In fact, they designed and supported alternative organizations to convince people who would otherwise support a universal single payer healthcare system that, that was not achievable, that this is what you can have and this is what you should be fighting for, and so divided the movement from the get-go. And I was a congressional fellow for Physicians for National Health Program, we met with members of Congress beginning in December of 2008 saying, just compare our proposal to yours. And as soon as the hearings began, it was clear that they were not going to include us in any way. The business round table was there, the chamber of Commerce was there, the CEOs were there, but we weren’t there. And so that’s when we had to step up and say, people need to know what’s going on here, this is being written by the corporations and not in the interest of people.

    Chris Hedges:

    Well, it was Fowler is that her name?

    Margaret Flowers:

    Liz Fowler was the architect, former vice president of WellPoint, one of the large insurance corporations. And she wrote the white paper and she with Max Baucus, who was the chair of the Senate Finance Committee, they really shepherded and oversaw that whole process. And then Obama appointed her to write the regulations at department of Health and Human Services, and now she’s wreaking havoc in Medicare, fully privatizing Medicare through this new center for Medicaid and Medicare innovation.

    Chris Hedges:

    I remember the time you saying the American public was being forced to buy what you call this defective product. And you talked about how there would be no control over so called copays, which of course, is proven to be correct. Take us from that point to where we are now, and we’ve seen all horrible moves by the pharmaceutical industry like insulin. Talk a little bit about how people are being priced out of medication which they depend on for their very survival.

    Margaret Flowers:

    Let’s look at the environment at that time where about 50 million people in the United States didn’t have health insurance, and so there was a demand to do something. And the health insurance corporations were panicking too because they wanted those people to be buying their product, and so the solution to them was force everyone to buy it or pay a penalty. And this was a new level of, not only was the government saying you have to purchase private health insurance, but we’re going to set up a market and we’re going to sell it for the insurance companies and we’re going to give people money to help them pay the premiums to the health insurance companies.

    The health insurance corporations get hundreds of billions of dollars of subsidies every year. And there was this message, they were trying to say, well, this is going to bring prices down because the health insurance companies are going to compete with each other and they’re going to have to lower their prices. No, they carved up the market and so most people have very little choice of which health insurance companies they can buy a plan from in their area. And while they said that people can’t be denied on the basis of a preexisting condition, what the insurance companies did, is they look at the regions and if they’re not making money in a certain region, they could just pull out. And so that’s how they get around having to actually pay for care.

    Since then, health insurance premiums continue to rise, the out-of-pocket costs continue to rise. And what’s really interesting, again, a new level of atrocity is that, because now these mergers that have happened where the hospital corporations have their own insurance, they own the labs, they own the practices, if a doctor actually is trying to provide too much care to their patients, they can just pull their health insurance, kick them out, and then they lose all of those patients.

    Also, if a certain department pediatrics, OBGYN, psychiatry, if it’s not making money for the hospital, they just shut the entire department down. That’s happened in Maryland through our nonprofit MedStar. They gave two days notice at one hospital that serves a majority Medicaid population, they were shutting down the entire pediatric department, including the pediatric emergency room, the Center for children who’ve been abused, shut it down.

    Chris Hedges:

    Let’s talk about drug prices.

    Margaret Flowers:

    And drug prices-

    Chris Hedges:

    And also the way they’ve closed, those in rural populations are even being served?

    Margaret Flowers:

    … Well, when it comes to drug prices, what people need to know in the United States, is that there is no rational basis for the pricing of any of our healthcare services, it’s basically what they can get away with. And so that’s what we see in the pharmaceutical corporations, not only charging as much as they can for medications that people’s lives depend on, so what choice do you have? You have to pay that price, but also, for certain medications that are not expensive to make, but they can’t make as much of a profit off of it, they just stop making. So it’s not about health or what we need, it’s about what that market can get away with.

    And people should know that when they bring these new drugs on the market, most of the time they’re just tweaking a chemistry from the previous one, but they patented, they give it a new name, they don’t have to prove that it’s better than what they had before. So they pay their whole army of drug pushers to go out into the practices and strong arm the doctors to sell their products, so that’s not in the interest of people at all.

    And then we talked about our hospital supply, particularly in the rural areas, but also in low income urban areas, these corporations come in, they buy up the hospitals, they run them into the ground, and then they just sell them off to be developed in the cities. They become luxury condominiums in the rural areas, they just shut them down. And this really destroys some of these small communities because in some places that local hospital’s a big provider of jobs, but also might be the provider of services like an ATM machine or the other things that they couldn’t get in their town.

    And so in the United States in 1975, we had about 1.5 million hospital beds and a population of about 216 million people. Now, with a population of over 330 million people, we have around 925,000 beds, so we’ve lost a significant number of beds. And that hurt us during the pandemic when we saw our hospitals getting overwhelmed and we just didn’t have the facilities to handle these patients.

    Chris Hedges:

    It is racialized in a sense that it’s poor people of color who pay the worst price in terms of mortality statistics, especially. There was an article in the New York Times that poor people on insulin are trying to ration their insulin, they’re not taking the full dose, but this, of course is, if not ineffective, it’s certainly harmful. But let’s talk about that racial component.

    Margaret Flowers:

    Well, in the United States healthcare system, let’s be honest, it’s been a racist system from its very onset. And that continues today and I think there’s starting to be a little bit of a reckoning that, we do have a racist healthcare system. But look at the COVID-19 pandemic, because that really exposed this problem, and part of it was not prioritizing communities of color and getting masks and vaccines and things that they needed and education out to them.

    Part of it was that, there is a justified distrust of the US healthcare system by a lot of people who live in Black communities because they haven’t been treated fairly and have been actually experimented upon, let’s be honest, with no regard for their health or their lives. And then look at who are the essential workers and how were they treated and not being forced to work in conditions where they knew that they were facing risks of getting sick or dying and weren’t protected? So the number of OSHA complaints skyrocketed early in the pandemic.

    And so now we see that, when you look at who gets sick with COVID and who dies, is it’s three to four times more likely that a person of color is going to be infected, is going to die. And what’s interesting is though, if a person of color gets infected and gets into the hospital, for some reason, they have a better outcome than someone who’s White. I can’t explain that, there’s no biological basis to race, but that’s the experience that we’re seeing. But still, their life expectancy has fallen much faster than life expectancy for white populations and I think that much higher proportion of people who are Black are in medical bankruptcy.

    Chris Hedges:

    Well, we see, life expectancy is falling-

    Margaret Flowers:

    Consistently.

    Chris Hedges:

    … In terms of maternal deaths and births.

    Margaret Flowers:

    Much higher. [inaudible 00:16:11]

    Chris Hedges:

    It’s going up, especially of course if you’re black or brown. Let’s talk about how the medical system is endangering the health of a public which doesn’t go for preventative care because they can’t afford it. And then even when they are sick, they won’t go. You’ll periodically read these stories about people, they may be injured or sick, but they don’t want to get in an ambulance because they can’t afford the thousands of dollars you’re charged from being driven to an emergency room.

    Margaret Flowers:

    Getting sick or injured in the United States is scary, not just because you’re sick or injured, but because you could ruin your whole life and your family financially, people go bankrupt, they lose their houses. So whereas in other wealthy countries, we’re the only wealthy country that doesn’t have a universal system. People make the decision about whether to go see a doctor based on what they’re feeling in the United States. First is, you recognize I might need to see a doctor, the next conversation you have is, can I afford to go see that doctor? Can I afford to be diagnosed with a life-threatening condition? And so people make really difficult choices.

    And it’s interesting because there was a RAND study that showed that no matter what your socioeconomic status, your level of education, people without a medical background are not able to make a good decision about whether they should go or not. So having this incentive to not go, people are not good at making that decision about when it’s life-threatening or not, is the point I’m trying to make. But to me, people talk about their concerns of having a universal system because there might be some rationing. In the United States, we ration healthcare in the cruelest way possible based on a person’s ability to pay. And I know of people who’ve made decisions not to get cancer treatment because they wanted to keep their house, people who committed suicide because they didn’t want to bankrupt their family, this doesn’t happen in other wealthy nations.

    Chris Hedges:

    Let’s talk about what is done to the medical profession. You have huge shortages of nurses, doctors, the privatization of every aspect is essentially driving people out of the medical field.

    Margaret Flowers:

    This is really a very sad thing because I remember years ago talking to physicians who said, we think most of the doctors in the United States are in some stage of grief, denial, anger, because of the way you do this training, you want to get out there and take care of your patients and then you just start running into obstacles everywhere. And now medicine has become so corporatized that even those little family doc practices or pediatric practices, they’re going extinct because the insurance companies will drop you and you are forced into a corporate system so that you can still be in that insurance so that you could still see your patient and then you don’t have any autonomy.

    And I remember meeting with some doctors at their lunch break in a big practice, and they were all worried that day because their numbers were coming out and were their numbers going to be, and that’s not what doctors should be thinking about. And so it’s really demoralizing to physicians, and it’s one of the reasons why I left practice, is because you can’t, all the incentives are against doing what you need to do for your patient, you have to fight for every little thing, and that has to change.

    Chris Hedges:

    But also because it’s profit driven, they strip staff down in hospitals.

    Margaret Flowers:

    Nursing staff, physician staff, the nurses are completely overworked, and you can’t provide good care in that environment. The nurse is really the eyes and ears and the direct caregiver, and you can’t give the necessary care if you have way too many patients to take care of. And so it takes a toll on everyone within our healthcare system because it’s about profit. And here are people who actually want to do some good things and you’re prevented from that.

    Chris Hedges:

    Let’s talk about what the trajectory is. As I mentioned in the opening, these profits are obscene, these bonuses are obscene, but they’re carnivores. Where are they taking us? What are they doing at the moment?

    Margaret Flowers:

    Well, they’ll stop at nothing, as we saw Maryland, where they’re stripping essential services from hospitals that have served communities in order to build these huge surgical centers that do cardiovascular and orthopedic, because that’s a big moneymaker. So where are we going to go for our OBGYN care? Where are we going to go for our pediatric care with this type of trajectory and shutting down the hospitals?

    I remember it used to be that Black people were turned away from hospitals and they had to drive miles and miles and miles to try to find a hospital that would take them in. Now, this is everybody in the rural community, the hospitals just aren’t there, and you’re driving. And that has impacted higher mortality in these communities from preventable causes if they had healthcare. So this is not sustainable, it’s not sustainable based on the way that we’re treating the health professions. At some point, because this is an issue that touches on every single person, this is going to have to change.

    Chris Hedges:

    And yet they’re disempowering those segments, veterans, the VA, or medic people who actually have a system that functions, they’re destroying it.

    Margaret Flowers:

    They’re privatizing the VA, and of course, they cloak it under, this is better for our veterans, they’re going to have more choice. Where have we heard these words before? People in Moscow are not even aware of what’s happening to Medicare, but the goal, as stated by Liz Fowler’s Center for Innovation, is to have it fully privatized by the year 2030. And what does this mean for seniors? It means that you’re going to be in the same boat as people who have private health insurance, where you have high out-of-pocket costs, you’re denied care. We see through these Medicare so-called Advantage Plans, people who need rehab, they’re kicked out early, they can’t get the necessary rehab that they need, this is devastating. This was a program that was meant to serve our senior and our chronically ill population and it’s another profit making center now for the private corporations.

    And same with Medicaid, the vast majority of people in Medicaid are in these private, they’re in MCOs called a managed care organization. These managed care organizations can take 40 to 50% of the money they receive from the government for their administrative, their pay, their salary. Whereas traditional Medicaid, it’s 2% that goes into administrative costs. So that’s robbing money that could be used to pay for care for people.

    Chris Hedges:

    Well, let’s talk about where we’re headed. You mentioned earlier that it’s not a sustainable system, certainly in terms of public health, it may be sustainable for corporate profit, but where are they driving us? Where are we going to go?

    Margaret Flowers:

    Well, where we’re going right now, and Congress is aiding and abetting this, they just continue to find ways to give people the illusion that they’re doing something about the problem, but every time it means either throwing more money at the corporations or giving them more tax breaks or protecting their profits, their interests. But I think this is not going to be sustainable for the American public. And we see that the polling data shows that people support having a healthcare system. And it’s interesting because what’s been even people who consider themselves to be conservative and traditionally, we support the market, are more and more beginning to understand and say, no, I like my traditional Medicare. I like being able to choose my doctor and be able to get the care that I need. So I think public sentiment is going to continue to grow.

    And also, I just see so many organizations and groupings within the United States who advocate on other issues, but who also understand that we need a universal healthcare system. So this is really becoming part of their demands as well. So the trajectory we’re on is not a good one and it depends on how much Congress can get away with continuing to funnel public dollars into these private corporations. But I think from a popular level, more and more people, as they continue to see that nothing is done and they can’t afford their healthcare and their loved ones are dying, they’re going to do something about it.

    Chris Hedges:

    But it’s even worse than not being able to afford it, it’s increasingly more expensive. It’s not just that it prices out a large segment of the population, but year after year, a larger and larger segment is priced out.

    Margaret Flowers:

    And it’s eating up more and more of our GDP, so nobody is safe in this. I know of people who were fairly well off prior to an important illness and ended up losing everything anyway, so nobody is-

    Chris Hedges:

    And we should be clear that a lot of these people have insurance.

    Margaret Flowers:

    … If you look at, so as you mentioned, medical bankruptcy is the leading cause of personal bankruptcy in the United States, medical illness. And more than around 80% of people who went bankrupt due to medical illness had health insurance at the onset. But we have a system that ties health insurance to employment and that’s another situation that makes no sense at all, not only because it gives the employers a lot of control over their workers, and that’s why every worker should be opposed to that. But because as soon as you become ill, you risk losing your health insurance at the time that you need it the most, it makes absolutely no sense.

    Chris Hedges:

    And yet the Democratic Party is completely complicit in all of this, that they sometimes mouth, like Obama, the right words, but they’re captive to the healthcare industry.

    Margaret Flowers:

    And then they wonder why people don’t want to vote for them. Because if they make these promises and they absolutely work against it in every way. And what’s interesting, is the few champions I knew in Congress that tried to hold strong and push, in some way, they were pushed out. And Dennis Kucinich was the last stalwart, and I remember that just before the vote on the Affordable Care Act, and he was the last one voicing opposition, President Obama flew him on an airplane to his district and held a big rally and got out there and said, we’re going to do healthcare and it’s going to be great and then he pushed Dennis out there and said, so what are you going to do, Dennis? And he told him on the way back in the plane, if this goes down, I’m blaming you. It was a tremendous arm twisting and manipulation.

    Chris Hedges:

    I think Dennis voted for it, didn’t he?

    Margaret Flowers:

    I can’t remember if he did or not-

    Chris Hedges:

    I think he did.

    Margaret Flowers:

    … He may not have needed to have his vote for it, but anyway, if it had gone down, it was all going to be placed. And then he ended up being redistricted and pushed out right after that anyway, they punished him for daring to speak.

    Chris Hedges:

    How do we break the back of a healthcare industry whose lobbyists control the legislative process? And I would also ask you just in the closing minutes to talk about the coverage because if networks like CNN rely on their advertising, the voices like yours are essentially not only at the best at margins and usually shut out.

    Margaret Flowers:

    We are, and that was the interesting thing during the Affordable Care Act, Obama’s personal physician was invited to the White House as part of an ABC thing, and I think it was April of 2009. And then he was quoted in an article saying he thought we should have a universal healthcare system and he was dis-invited. We had Dr. Quentin Young who served as Dr. Martin Luther King’s personal physician and Obama’s personal physician asking the Washington Post to let them write an op-ed, and they wouldn’t even talk to them.

    This was the collusion and it all has to do with what we call interlocking directorates, where the CEOs of these corporations are also on the boards of these media outlets and the advertising dollars as well, so they wield tremendous power. So people need to understand that a lot of the information that they’re getting is not accurate information, they package these things, they make them sound really good. But right now, Congress is aligned with these corporations and they donate equally to Republicans and Democrats, and especially if they see that one party is likely to take over and they’re going to be in charge of the committees, then they really pump a lot of money into that party.

    We win this the same way that we’ve won every other battle, we have to educate ourselves and others, we have to speak out about it, we need to connect. We need to understand that health is fundamental, it’s connected to everything, and that there is no incremental way that we can do this. We cannot work within the for-profit system to fix this problem, we have to nationalize our healthcare system. And that means getting the profit out completely, and that’s unfortunately in the bills that are in Congress right now, they don’t take that step. They continue to try to allow the for-profits to operate within the system, but they’re parasites and they’re always going to push it and take as much as they can. And every dollar they take means a dollar less of somebody getting the care that they need.

    It’s the fundamental, it’s education organizing, connecting this to other issues and putting pressure and taking action on our own communities. There are a lot of efforts that people can take locally to try to save their hospitals to set up alternative formations. We saw that during the pandemic, Black doctors going into communities and taking care of people there. These are the things we need to, at every level, be doing in our country.

    Chris Hedges:

    One of the little pieces of trivia I learned covering the campaign was that they sponsored the candidate’s debates, that’s why they lock Kucinich out. The Debate Commission is a private corporation, and it had pharmaceutical and insurance money to run.

    Margaret Flowers:

    That’s the whole other thing, it’s the ads called the Commission on Presidential Debates, but it’s a completely private entity. And that’s one of the main reasons we don’t have democracy in this country, is because all the other voices, if you’re not part of the Democratic or Republican Party, is shut out of the debates.

    Chris Hedges:

    Great. That was Dr. Margaret Flowers, advisor to the Board of Physicians for National Health Program. I want to thank the Real News Network and its production team, Cameron Granadino, Adam Coley, David Hebden, and Kayla Rivara. You can find me @chrishedges.subsdeck.com.

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