Author Archives: dave

Medical Care Rip Offs in the U.S. Medical Care System

Posted on by

By:

Kent Comfort

This is a true account of an actual incident. The names have been changed because the reader has no reason to know who they actually are.

Paul and Rhonda Martin were involved in a bad auto accident several years ago that resulted in Rhonda being transported by ambulance to a regional hospital emergency room, followed by an overnight stay for “observation. Rhonda was quickly examined for any sign of injury that may need immediate attention or treatment. Nothing serious was determined.

Rhonda was released at noon the next day. Other than the muscle aches and pains that would be expected from such an incident, she had no new complaints and was very ready to be dismissed so she could return home.

Because this was an auto related incident, the medical coverage that was part of the auto insurance policy was the source of responsibility for all charges related to medical care. Paul and Rhonda had sufficiently high limits on their policy to easily cover all expenses. No out of pocket payment was required. That’s the end of this story, right? That would be wrong.

When the bills started coming in the mail, that Sunday afternoon outing ending in a vehicle crash generated nearly $40,000 in expenses and revenue for all parties involved with providing care to Rhonda. The hospital ER visit and overnight stay alone totaled just over $35,000. And there was no treatment or procedures performed, no medications prescribed, and only dinner and breakfast were provided in the hospital room. And Rhonda stated that they were not that delicious!

When Paul reviewed the hospital statement, he was alarmed at some of the items listed and their charges. One charge in particular stood out as a very likely error. It was over $11,000 for a neurologist. Rhonda was not examined by any neurologist. The closest they came to contact with medical personnel was a brief visit by an intern in training and a couple of nurses.

Paul called the hospital business office to clear up the mistake. The clerk initially agreed with Paul that the statement needed closer scrutiny and verification of charges. Paul received a call the next day, and here is what he was told.

“The $11,000 charge is correct. This is due to the fact that there was a neurologist on site, and if Rhonda had needed that level of care it was present. The charge is for the presence of this level of care if needed. And that is standard policy.” Hence, the hospital insisted that the charge was not a mistake at all!

Even though the Martins considered such a response to be alarming, and even unethical in their view, there was no financial impact on them because if it. Paul even called the auto insurance company and they brushed it off as inconsequential and assured Paul there was no reason to be concerned. They would pay the bill as presented and that would be the end of the story. But here again, that would also be wrong. Fortunately for both Paul and Rhonda, the injuries never amounted to anything more than a few aches and pains that were just a memory three weeks later.

A little over two years later, the Martins received a letter in the mail informing them that a class action lawsuit had been filed against the hospital for excessive and questionable charges to clients. They were invited to join the suit as plaintiffs by filling out an enclosed form and returning it by a stated deadline date. They were surprised by this turn of events, and promptly completed the form and mailed it back in the enclosed envelope. Approximately six months later, they received an unremarkable looking postcard that referenced the class action status and required a signature and return. It was so innocuous in appearance that it would have been very easy to overlook and toss in the trash.

The next communication regarding the lawsuit was a letter announcing that the case was successfully completed, and a substantial judgement had been won on behalf of the plaintiff group. After all matters were settled, payments would be disbursed to all plaintiff clients in the near future. No dollar amounts were disclosed in the letter.

Enough time elapsed after that communication that the Martins almost forgot anything was still in process. And then nearly a year later, after they had just returned from a trip, they sifted through the pile of mail that had accumulated during their absence. There was, once again an innocuous looking envelope with no revealing identification visible. It was cleverly presented to look like typical junk mail containing advertisements. Paul and Rhonda have always been diligent about opening all their mail. And this time it really paid off. Enclosed was a check for their portion of the settlement, amounting to over $20,000! And that is almost the end of the story!

Many questions arise from the facts presented here. For example:

  • Why did the hospital think they could get by with assessing such outrageous charges for essentially no services of consequence provided?
  • Why do auto insurance companies accept these excessive charges without raising any questions on behalf of their clients?
  • Is it correct to assume that auto insurance rates are much higher than they should or to be because of their lack of prudence?
  • How many people who received an invitation to join the class action suit may have been inclined to just toss the letter?
  • Even more disturbing, how many people may have thought the envelope containing the check was junk mail and tossed it?
  • Has it become standard practice in the American medical industrial complex that a common solution for adjusting costs includes class action lawsuits?

This is a very brief list for what could easily become a very long list of questions about how broken the American medical service delivery process truly is. The final question might be is there anything that can be done about it in our present sociopolitical environment?

The Medical-Financial-Industrial Complex & the Maldistribution of Wealth in the United States

Posted on by

By:

Dave Kingsley

Introduction

In the previous post, my colleague Kent Comfort presented a case study pertaining to the disappearance of middle-class wealth into the Medical-Financial-Industrial complex black hole.  Even frugal, hardworking individuals who believe they have saved enough for retirement often find their assets depleted quickly due to high-cost, industrial medicine.  In this and future posts, we will be explaining how wealth is being maldistributed in the United States and how the government-funded industrial-medical system is helping to drive wealth from the bottom 90% to the top 1%.

The shift in wealth and the influence of U.S. medicine on the flow of assets from the lower socio-economic classes to the wealthiest class is a threat to the economic system and socio-cultural stability.  According to the PEW Research Foundation, “The wealth divide among upper-income families and middle- and lower-income families is sharp and rising (https://www.pewresearch.org/social-trends/2020/01/09/trends-in-income-and-wealth-inequality).

Since the 2008 economic crash, most of the growth in U.S. family/individual net wealth has gone to the upper 5 percent.  The share of U.S. wealth owned by the bottom 90 percent of the population fell from 33 percent to 23 percent.  Wealth of the top 1% increased from 30 to 40 percent (https://equitablegrowth.org/the-distribution-of-wealth-in-the-united-states-and-implications-for-a-net-worth-tax/). This macroeconomic factor not only an economic injustice, it is a threat to the U.S. capitalistic system and democracy.

You pay taxes, premiums, and out of pocket expenses to fund large reimbursements to insurers, providers, and vendors, i.e., the insurance, hospital, medical device, pharmaceutical, nursing home, and other ancillary medical services industries. And yet, health care in the United States can bankrupt you.  Indeed, many people have been bankrupted through exorbitant hospital and nursing home costs. 

If the money you would like to leave to your heirs disappears in the U.S. industrial medical system, you would probably like to know where it goes.  It doesn’t go back to the Medicare, Medicaid, Obamacare, and VA programs ostensibly paying for your treatment.  Those programs are replenished through federal and state taxes – with the heaviest burden falling on the middle and lower classes.

So where, other than treatment, does all that money you pay in taxes and spend out of pocket for health care go?  The simple answer is, it goes to shareholders in one form or other.  In the 1970s and 80s, the country decided that private enterprise, operating in a “free market,” would be the most efficient and effective medical care delivery system.  What we got was an inefficient, ineffective, corrupt, and far too expensive industrial medicine system that funnels your hard-earned assets into the pockets of high-net-worth individuals and ultra-rich individuals and families.

From Your Family to Their Family:  How Laws Have Been Engineered to Keep Upper Income Wealth Growing While Everyone Else’s Continues to Shrink

Wealthy individuals despise two things: taxes and inflation. In fact, Leona Helmsley was jailed for telling an ugly truth: “We don’t pay taxes, the little people pay taxes.”  By little people, she meant most of us who are not rich.  Hence, the wealthy purchase politicians that protect their wealth from inflation and taxes – “purchased politicians” include practically all elected legislators in both parties. 

Shareholders in the industrial medical system tend to be high-net-worth individuals ($30 million or more in assets) or ultra-rich families worth hundreds of millions and billions. Inordinately complex federal and state tax laws have complexified corporate and individual finances, which works to the advantage of owners and shareholders.  For instance, throughout the past few decades, the state of South Dakota has amended its trust laws and has become a haven for wealthy individuals and families seeking trust laws that protect their wealth from inheritance and other forms of taxation.

It future posts, we will be taking a deeper dive into how Medicaid and Medicare funds are fueling the flow of wealth up the SES ladder.  For instance, more of those funds are flowing into family trusts than people realize.  In fact, the amount of nursing home ownership by family trusts is extensive and unnoticed by the public.  We will expose which chains are funneling a considerable amount of revenue into family and individual trusts.

How The U.S. Medical System Transfers Working Class Wealth to the 1%: A Case Study

Posted on by

By:

Kent Comfort

Mary’s Story: This Could Be You!

Mary Beacher has just retired after four decades of working for a large regional printing company as a type setter. She went to work for this company two months after graduating from high school. It was the best employer in her town, and she counted her lucky stars that she was able to secure a job there. And she worked hard to be a dependable model employee.

When she first started working for the company, they had an employee pension plan that the company paid into on behalf of all workers. In the 1980s, that pension plan converted into a 401k account for each individual employee, with their pension accruals transferring over to this new financial instrument. Mary did not understand the nuances of this. She just trusted her employer to look out for her retirement nest egg when she would reach that time. Mary would receive a statement annually that showed the value of her personal retirement fund. And her excitement grew every year after about 30 years had passed, because the amount it had grown was very impressive to her.

When retirement day finally came, Mary learned she had just over $500,000 waiting for her to fund her way of life. She had always made a very modest salary, and she was not a financial expert in any way, so this seemed like more money than she could ever imagine she would need to support her modest lifestyle. She had no plans for moving away from the small community she had always lived in. Almost everyone that mattered to her lived there. Where would she go?

Three years into her new leisurely life, Mary had the misfortune of experiencing some serious health problems. Since she lived alone and her only daughter lived far away with her own family, Mary did not have any family close by to provide care and support, and she was not able to look after herself because of her ailment. Her doctor recommended she look into skilled nursing care at a local nursing home that was owned by a national chain. Her doctor’s reasoning was that since the facility was owned by a huge company, it must be safe. He had heard occasional complaints from families of residents, but nothing that alarmed him. As elderly folks are commonly inclined, she took her doctor’s advice and allowed herself to become a resident, hopefully for only a short while until her health improved and she could go back home.

Mary’s health did not improve. Some would say the primary reason for this was the environment she was in was depressing and she felt like no one was really watching out for her or cared about her. And sadly, she was more right than wrong about this feeling.

The biggest shock came when she learned that the monthly cost of her staying in this facility was over $10,000. She no longer had health insurance from her employer after she retired. She was enrolled with Medicare, but she was not eligible for coverage from that source because her case was not about rehabilitation. She was a skilled nursing client. She discovered she would have to foot the bill for her care on her own until all her funds were exhausted. Then she would qualify for Medicaid in her state because she could claim to be in a state of poverty at that point.

And that is the story about how the Mary Beachers all over America have their entire personal wealth extracted through health industry policies, all of which are legal. Mary’s personal wealth did not go into government accounts. It went into the accounts of the large, very wealthy corporations that own the senior care properties all over the country. And that money then flows to a very small number of wealthy families who own these corporations. Due to very favorable tax laws and policies, these families pay a lower percentage of taxes than Mary did when she was earning her salary at the printing company!

So, let’s recap Mary’s situation. Her hard-earned personal wealth, from four decades of being a trusted and loyal employee at a local printing plant, in a very short time period was transferred entirely to a wealthy family through the legal policies of the American health services system.

And this could happen to you as long as our policies and systems remain as they are today. But that is not the end of the story….

See: The Medical-Financial-Industrial Complex & the Maldistribution of Wealth in the United States by Dr. David Kingsley on this blog site.

WARNING! The Mainstream Media is Writing COVID-related Deaths in U.S. Nursing Homes Out of History.

Posted on by

By:

Dave Kingsley

If you visit your local Barnes & Noble store, you will find three new arrivals chronicling the COVID-19 scourge:

Washington Post journalists Yasmeen Abutaleb & Damian Paletta: Nightmare Scenario:  Inside the Trump Administration’s Response to the Pandemic that Changed History (New York:  HarperCollins).

Freelance writer John Sternfeld (Introduction by New York Times Columnist Timothy Egan): Unprepared: America in the Time of Cornovirus (New York: Bloomsbury Publishing).

New Yorker staff writer Lawrence Wright: Plague Year: America: America in the Time of COVID (New York:  Alfred Knopf).

This post is not a full-fledged review of these books.  I have read them and find them disturbing because of what they don’t say.  I’m warning the “less physically abled” people of America needing skilled nursing and long-term care that they are being disappeared from history.  That puts those people we dehumanize as “frail” and “disabled” out of sight and out of mind, which puts them at great risk.

Authors of these books have ignored the estimated 140 to 200 thousand mostly unnecessary deaths and suffering of patients and their families due to dereliction of the nursing home industry and government regulatory agencies.  Their focus is on Washington, D.C., inside the beltway politics and the Trump Administration’s handling of the pandemic (sans nursing home related issues). 

It is not surprising that Timothy Egan’s introduction to Sternfeld’s book ignores the “nursing home tragedy” altogether.  He has, in the past, demonstrated hostility toward the “elderly.” In an NYT column he claimed that “pill popping seniors” were robbing younger generations.  He was referring to the cost of Medicare, which he failed to recognize is paid for by the beneficiaries through a payroll tax and out of pocket expenses. I remember this column so well because I was in Washington circa 2012 on many occasions lobbying to stop cuts in Medicare and Social Security.  NYT columnists like David Brooks and Timothy Egan were accusing the aging population of selfishness merely because of their audacity to fight for the benefits they had worked hard to earn.

The Silence of Professional and Advocacy Groups is Deafening

COVID-19 resulted in a horrendous failure of care and protection for the institutionalized less abled among us, i.e., those individuals institutionalized in the so-called “nursing home system.”  Not only were government agencies and corporations charged with the care of millions of patients in skilled nursing and long-term care facilities derelict, but professional organizations comprised of physicians, gerontologists, and advocacy groups such as the AARP were reticent and vacuous in speaking out about the preventable mass fatalities occurring in these government-funded and regulated institutions during 2020 – and remain so to this very day.

How elites and paid professionals and the organizations in which they are employed react to the massive loss of life in SKN/LTC facilities will greatly impact the public attitude toward the value of Americans with physical barriers preventing their full independence and participation in society.  Ignoring the unnecessary loss of life in the institutions ostensibly designed for humane care will send a strong signal about what we can expect in the years ahead.

Another Conversation with Charlene Harrington

Posted on by

We welcome back Charlene Harrington for another conversation. In this session, Dr. Harrington updates us on some alarming statistics and related details regarding the impact of Covid in nursing homes throughout America. She informs us that there are currently approximately 3.1 million residents in these facilities, of which 1.3 million became infected. We also learn that Scandinavian countries are thirty years ahead of America with their methods of caring for their elder populations.

The U.S. “Nursing Home System” Is Exceedingly Corrupt: Advocates, Activists, and the Media Need to Focus More on That

Posted on by

Faux Capitalism Fueled by Political Contributions: “The Mother’s Milk of Politics”

Due to his aphorism that “money is the mother’s milk of politics,” most of us involved in California politics in the 1960s and 70s will never forget Jesse Unruh – the powerful leader of the California Assembly at the time. Little could we know to what extent that brutally honest insight would come to dominate American political processes.  Nor could we know that Eisenhower’s warning about the military-industrial complex would eventually be relevant to the medical care industry.

The so-called nursing home system is an exemplar of industry patronage dispensed to legislators for the purpose of cash extraction at the expense of quality care – care that all Americans deserve for the taxes they pay.  Unfortunately, this reality is not a factor in public political discourse. And it will not be a factor unless advocates and activists do more to press the issue.

The public is fed several myths about the fundamental nature of government funded long-term care in the United States.  The myth that providers are operating in a competitive, free market, system drives the propaganda disseminated by trade associations such as the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

The truth is that licensed providers – both privately held and publicly listed – are entities in a faux-capitalistic system in which prices are guaranteed by federal and state governments while wages and working conditions remain weakly regulated.  Price controls are advantageous to the industry.  Conversely, the lack of wage controls and employment protections are a disadvantage for workers.  Weak federal and state regulation of care is harmful to patients.

At Congressional Hearings, Advocates are Testifying to Legislators Who Receive Money from the Industry:  Both Democrats & Republicans

The toxic and perverse form of capitalism represented by the industrial medical system is maintained through a political juggernaut in the form of finance, real estate, hospital, nursing home, and other industrial lobbying groups often mistakenly called the medical-industrial complex.  Actually, those of us who advocate for enlightened skilled nursing care, are up against the Finance, Insurance, Real Estate (FIRE)-Industrial Complex.

Wall Street and its affiliated trade associations (e.g., AHCA/NCAL) distribute immense amounts of money to legislators to maintain the highest prices for the least amount of care in skilled nursing facilities.  Evidence to support this situation can be found through several sources.  For example, the website OpenSecrets (https://www.opensecrets.org/) does an outstanding job of exposing the flow of money through Washington, D.C.

Democrats are Favored by the AHCA/NCAL

In 2018 cycle, the AHCA/NCAL PAC distributed $610,616 to federal candidates (American Health Care Assn PAC Contributions to Federal Candidates • OpenSecrets).  Democrats received $401.616 (65.77%) and Republicans received $209,000 (34.23%). 

The top recipients of the industry’s patronage are some powerful legislators.  The top 10 contributions were dispensed to the following legislators:

Vernon Buchanan (R-Fla)$10,000
James E Clyburn (D-SC)$10,000
Ben R Lujan (D-NM)$10,000
Frank Pallone Jr. (D-NJ)$10,000
Nancy Pelosi (D-Calif)$10,000
Peter Roskam (R-Ill)$10,000
Steve Stivers (R-Ohio)$10,000
David Young (R-Iowa)$10,000
Carlos Curbelo (R-Fla)$8,500
Cathy McMorris Rodgers (R-Wash)$8,500
Top Recipients of AHCA/NCAL PAC Donations

A $10,000 contribution swings a lot of weight.  Both Democrats and Republicans receiving these contributions are among the most powerful members of the U.S. Congress.  If you go through the entire list, your idealism regarding some of the more liberal members of the House and Senate might be shaken somewhat.

In the next few posts, I will be sharing more data regarding AHCA/NCAL distribution of money to lobbyists and how the revolving door advantages providers over patients.  Staffers and former legislators make much better money on K Street than they can make serving the public.

Professional Conflicts of Interests

As I perused the list of donors to the PAC, I recognized some of the contributors.  For instance, I noticed that Medicalodges, a mid-size, closely held, chain in the Midwest, made repeated contributions.  I’m familiar with Medicalodges for several reasons.  Some of their facilities are located in Kansas – a state in which I have done a considerable amount of LTC ownership research.

The Medicalodges board of directors includes Professor Gayle Doll – head of the Kansas State University Gerontology Program.  This inappropriate paid service on a provider board of directors is not the only conflict of interest in which professor Doll is engaged.  She is also managing a State of Kansas Grant known as the PEAK program, which dispenses Medicaid bonuses for facilities that can demonstrate development of a “home-like culture.”

She should have no role in evaluating providers for the purpose of Medicaid uplifts.  The last time I checked the Kansas Department of Aging & Disability Services (KDADS) website (https://www.kdads.ks.gov/), no adequate evaluation of the PEAK program was available to the public.  I called professor Doll about this and was told to speak KDADS.  KDADS told me to speak to professor Doll’s office.  Nursing home employees I know tell me that the program is a sham.  Providers do a little window dressing, make no substantive changes, and still receive rather hefty uplifts on Medicaid reimbursements.

Corruption is Pervasive and Deeply Ingrained in the Faux-Capitalistic Long-Term Care system

I have only scratched the surface in connecting some dots related to the corruption rife in the “nursing home” system.  With collapse of the medical-moral-ethical underpinnings of our healthcare system, legislators have become corrupted by money and professional conflicts abound due to a developing weltanschauung of self-interest over the public interest. 

Many more dots can be connected. We will do that as we “follow the money” in future posts. People who need long-term care are not consumers and the industry will not bother to market to them. The industry’s customers are legislators in federal and state legislatures. That is who they need to sell.

Executive Compensation for CEO’S of Major Nursing Home Chains did not Decline Significantly During 2020: For Most, it Increased by a Significant Amount

Posted on by

    The nursing home lobby operating in Washington and state capitals is continuing its long running financial hardship campaign.  An article in the latest issue of Provider (the main propaganda organ for the industry) claims that COVID presented such a serious financial blow to providers that enhanced financial assistance from government would be the only way to implement needed substantive reform. The reform needed, according to the article, is due to increasing demand in long term care services (Patrick Connole, “COVID Challenges Bring Opportunity for Systemic Changes,” June 2020, 9-10).

    The article states that “With the majority of nursing homes already operating on razor-thin margins, the cost of making improvement will not be possible without financial assistance.”  Perhaps the razor thin margins to which the author is referring apply to the LLC listed as the owner and not to all the other LLCs such as the property LLC, the management LLC, the rehab LLC, the medical transport LLC, etc.  Certainly, holding companies and REITs have not fared badly at all during 2020 and the height of the COVID pandemic.[i]

    One would think that the entities at the top of the financial food chain would have taken a major hit and pared back their CEO pay considerably if the razor thin margins at some point in the flow of capital diminished shareholder value.  However, as the table below suggests, CEO pay for major nursing home operator/real estate chains listed on a public exchange were either enhanced by a large amount over 2019 and 2018 or remained steady.

    The above table does not display the proportion of total pay that is due to an “incentive bonus.”  Nevertheless, in cases where a major increase year over year appears for an executive, a large amount is for performance, which one must assume is financial performance.  The loss of life throughout the companies overseen by the executives in the table was a historical first for institutionalized U.S. populations.  An estimated 132,000 to 140,000 people in the care of these CEOs unnecessarily lost their lives.

    The government funded companies headed by CEOs at issue in this blog post are increasingly powerful players in taxpayer subsidized long-term and skilled nursing. In blog posts ahead, I will be discussing the growth of their power and influence.  For instance, the ManorCare property sold off by the private equity firm The Carlyle Group is now owned by Welltower and operated through a Welltower-Pro-Medica joint venture.

In the future, I will be blogging about the convoluted ownership structures in the nursing home industry and the complexification of that facet of the business due to the creativity of corporate lawyers and financial experts. Without exposing the financial trickery employed by providers, the public will be victimized by falsehoods of lobbying groups such as the AHCA/NCAL and others.

NOTE: The data in this post were derived from proxy statements filed with the Securities & Exchange Commission. In the future, I will be discussing compensation for board members and other officers/executives of major LTC/SKn corporations.

[i] Kingsley DE, Harrington C. COVID-19 had little financial impact on publicly traded nursing home companies. J Am Geriatr Soc. 2021;1–4. https://doi. org/10.1111/jgs.1728

The “Care For Our Seniors Act” is a Ruse Used by the Nursing Home Industry to Up Reimbursements

Posted on by

LeadingAge & the AHCA/NCAL are Engaging in Harmful Propaganda:  They Need to Stop It!

Lobbyists for the nursing home industry, LeadingAge and AHCA/NCAL are promoting what they call “Care for Our Seniors Act,” which sets forth some laudable reforms they would like to see implemented along with an increase in funding (see:  https://leadingage.org/care-our-seniors-act).  I’m all for increasing Medicaid funding.  I’m all for some of the reforms they are pushing such as enhanced infection control preventionists, 24 hour registered nurses on staff, minimal personal protective equipment – all of which should have been in place before COVID. These are reforms that providers could have and should have provided and should now provide without more taxpayer funding that will be dedicated to increasing yield for investors.

Medicaid funding increases proposed by LA & AHCA/NCAL are all designed to increase reimbursement, e.g., “Enhanced Federal Medical Assistance Percentages (EFMAP).”  One of their ruses to get advocates on board is the proposal for a shift to private rooms by developing “a national study producing data on conversion costs and a recommended approach to make this shift.”  The study may happen, but the shift won’t unless the taxpayers are willing to pay for it – even though investors are extracting enough excess cash now to pay for these changes and still earn a respectable return on their investments.

The most despicable aspects of this proposal are the falsehoods used by LA and AHCA/NCAL for political framing.  For instance, their propaganda in the link cited above totally exonerates the industry and blames staff and government – not the real owners, i.e., investors, for lack of pandemic preparedness.  They fail to mention the generous COVID related federal and state subsidies provided to the industry, which were funneled into stock dividends and executive compensation.  This statement appeared in the latest issue of Provider, the industry’s trade publication: “With the majority of nursing homes already operating on a razor-thin margins, the cost of making improvements will not be possible without financial assistance.”

The nursing home industry and their lobbyist propagandists are treating advocates, activists, scholars, legislators, and the public in general with extraordinary disrespect. That needs to stop! If the industry is not willing to provide evidence to support their “razor thin margins” nonsense and stop treating us all like imbeciles, then their proposals should receive absolute zero credibility and no support from any of us.

A Pandemic Hit Us in 2020 & Killed at Least 600,000 Americans: After a Century of Pandemic Experience, Our Government Was Derelict

Posted on by

By Max Skidmore*

Prior to the COVID-19 virus landing on U.S. shores, scholars in government policy, infectious disease, and epidemiology were warning policymakers about the inevitability of novel viruses that would put the health of Americans at grave risk. They were ignored. The following is an excerpt from an article I published in the Journal of Risk, Hazards, and Crisis in Public Policy 3:4 (December 2012) entitled “Anti-Government is Not the Solution to Our Problems; Anti-Government Is the Problem: Presidential Response to Earthquakes, Pandemics, and Violent Weather From San Francisco to Katrina.”

Presidents & Pandemic Policies In Our Past, & Future

Pandemics potentially form a greater threat even than storms and earthquakes.  They are nature’s rough equivalent of the neutron bomb that once was touted as a device that kills people, yet leaves the infrastructure relatively intact.  In 1918, an influenza pandemic killed some 675,000 Americans, more than died in World War Two, or even in the Civil War.  The wartime conditions ensured that men would be packed into crowded camps where disease would spread rapidly, while Democratic President Woodrow Wilson made matters far worse. His example demonstrates that it is insufficient for a president to be able and inclined toward activism. He must also give full priority to a crisis when it arises. Wilson rejected medical advice—even as the war was winding down—and continued to send troops abroad in crowded ships that ensured infection and became floating morgues.[1]

The Asian flu of 1957 was a far less lethal disease than the 1918 influenza, but it nonetheless led to some 80,000 flu-related deaths that year.[2] This is in contrast to a normal annual rate often reported to be about 36,000.[3] More recent estimates report a range, from around 3,000 to around 49,000, depending upon the type of influenza prevalent in a given season.[4] Regardless of which figures provide greater accuracy, they all demonstrate that even in a normal year influenza is hardly a benign disease. Nevertheless, in 1957—as a pandemic was known to be developing—Republican President Dwight Eisenhower rejected medical advice, concluding that the free market would be sufficient to provide safety for the population.  He considered a government-sponsored vaccine program to be unnecessary.[5]

Eisenhower’s reliance upon the “profit-driven marketplace” would have fit neatly into the post-Reagan ideology of American conservatives, and the results were the same for Ike that they later were for his successors, most notably George W. Bush. For Bush, as is well known, the move toward privatization of Medicare in the “Advantage” plans, instead of saving money led to greatly increased expenditures. For Eisenhower, the inherent inefficiencies of the market approach that he adopted caused a huge and unnecessary loss of life.  Those inefficiencies of the vaccine market included inadequate production, poor distribution, and a diversion of vaccine toward corporate employees to reduce sick days, and thus away from high-risk groups.[6]

Republican President Gerald Ford, in contrast to the passive Eisenhower and certainly to the militantly contrary Wilson, was quick to act when facing the threat of a pandemic.  He decided upon a massive immunization program in 1976 when a new influenza virus was discovered that seemed similar to the one that caused the 1918 catastrophe.  As a result of Ford’s speedy action, his National Influenza Immunization Program (NIIP) succeeded in immunizing some 50 million Americans in short order.  Because no pandemic developed, and because a few cases of Guillain-Barré syndrome arose among those vaccinated, the administration abruptly halted the program.  Ironically, it was the government’s sophisticated monitoring system that identified the incidence of GBS, which otherwise would never have been noticed.  It was not faulty vaccine, and the cause of GBS was (and remains) unknown, but those vaccinated did have a sevenfold chance of developing GBS as compared with the unvaccinated.[7]

The overwhelming reaction of the media and the public was that the NIIP was a fiasco.  Despite the negative perception, however, Ford’s program demonstrated that it is possible for government to act effectively; with the proper skill and will, it can move rapidly to counter influenza and other pandemics.  It is feasible for a public program to vaccinate massive numbers, even in the face of great obstacles.  If the pandemic had developed, even more people—far more—would have received the vaccine, and Ford would have been a national hero.  As it was, his critics—the media, Democrats in the successor Carter administration, and especially the Reagan Republicans—distorted the record and made him look foolish.  Of perhaps the greatest long-term consequence with effects still prominent today, the Republican conservatives, aided by compliant news media, portrayed government as impotent, if not actually pernicious.

Distance, though, should add perspective—even if that perspective has yet to develop. According to the World Health Organization, the world in late 2009 fell into the grip of another pandemic caused by an H1N1 flu virus (the 1918 flu was also an H1N1). Richard Wenzel, a specialist in infectious diseases at Virginia Commonwealth University, wrote in an op-ed in the New York Times that, although “the epidemic never became as deadly as we initially feared, it was not as mild as some experts now believe. What’s more, it exposed some serious shortcomings in the world’s public health response.” He pointed out that no virus should be considered mild that “was so devastating for young adults, along with pregnant women, obese patients and minorities,” and said that of 94 poor countries, only 26 had thus far received any H1N1 vaccine. He praised the actions of the Mexican government, but said that in the U.S., there were “huge infection-control problems.” Among these, “at times, health officials erred in their recommendations,” saying that children and adults could safely return to school or work after fever had disappeared, even though they remained infectious. Moreover—and this is a key point—here, “the virus struck at a time when Americans seemed particularly skeptical about our government and large institutions.”[8] The Reagan legacy, if anything, had intensified.

Fortunately, the recent virus was considerably less lethal than its 1918 predecessor, did not appear to have mutated toward greater lethality, and—if the predictions of experts are accurate—is unlikely to result in another great wave of infection. If indications at this writing (April 2012) are borne out, humanity escaped an enormous tragedy. In any event, the lessons of President Ford’s NIIP, both positive and negative, are there to provide instruction to future policymakers.  They should serve as a guide to a society that someday will certainly face another horrendous pandemic, perhaps avian influenza, that could well be even worse than the 1918 pandemic. To his credit, in this regard former President George W. Bush did take action. In December of 2005, Congress granted his request for “3.8 billion to develop new vaccines and stockpile anti-flu medications.”[9]

[1] See John M. Barry, The Great Influenza (New York: Penguin Books, 2005); see also Carol R. Byerly, 2005. Fever of War: The Influenza Epidemic in the U.S. Army during World War I (New York: New York University Press, 2005), 108.

[2] Mike Davis, The Monster at Our Door: The Global Threat of Avian Flu (New York: Henry Holt, 2006), 35-36.

[3] Centers for Disease Control and Prevention, “CDC Finds Annual Flu Deaths Higher Than Previously Estimated,” Press Release (7 January 2003), 3.

[4] Centers for Disease Control and Prevention, “Estimating Seasonal Influenza-Associated Deaths in the United States: CDC Study Confirms Variability of Flu,” http://www.cdc.gov/flu/about/disease/us_flu-related_deaths.htm; retrieved 23 April 2012.

[5] Davis, Monster at Our Door, 35-36.

[6] J. Donald Millar and June Osborne, “Precursors of the Scientific Decision-Making Process Leading to the 1976 National Immunization Campaign,” Influenza in America: 1918-1976, June Osborne, ed. (New York: Prodist, 1977), 19-22.

[7] See Arthur Silverstein, Pure Politics an Impure Science (Baltimore: Johns Hopkins University Press, 1981).

[8] Richard P. Wenzel, “What We learned From H1N1’s First Year,” op-ed, The New York Times (13 April 2010), Opinion page.

[9] Sarah Glazer, “Avian Flu Threat: Are we Prepared for the Next Pandemic?” CQ Researcher 16 (13 January 2006), 1.

*University of Missouri Curator’s Distinguished Professor (Emeritus)

The U.S. Nursing Home System Incurred Massive Fatalities Due to System Failure. Will We Forget it Happened?

Posted on by

What Does the Death of 132,000 Institutionalized Patients Mean for the Past and the Future?

Officially 132,000 patients in the care of government funded and regulated skilled nursing facilities succumbed to the COVID-19 virus. The question with which we must now grapple is this: “Why did an unprecedented mass fatality occur to a specific institutionalized group of Americans?” Prior to COVID, the largest pandemic related sweep of death through an institution occurred in the military during WWI. Of the approximately 60,000 U.S. military deaths during the first World War, 40,000 were due to influenza.

Infectious disease experts warned us for decades that periodic pandemics would become the norm. In regard to COVID and the pandemics that preceded it, here is what Dr. Michael Osterholm and Mark Olshaker said in the preface to their new edition of Deadliest Enemy:

They all came as a surprise, and they shouldn’t have. Nor should the next one; and rest assured, there will be a next one and one after that, and on and on. And as we have outlined in this book, one of them will be even bigger and one or more orders of magnitude and more serious than COVID-19. Most likely, as we’ve written, it will be a novel influenza virus with the same devastating impact as the 1918-19 Great Influenza pandemic that killed between fifty and one hundred million people, but playing out in a world with three times the population, international commercial air travel, tinderbox. Third World megacities, encroachment of natural habitats that have brought animal reservoirs of disease to our doorsteps, hundreds of millions of humans and host animals living cheek by jowl, and a planet-wide just-in-time supply chain delivering everything from electronics and auto parts to lifesaving medicines without which the most advanced hospitals cease to function.

Michael Osterholm & Mark Olshaker, Deadliest Enemy, New York: Little, Brown, Spark

What Does One of the Few Few Experts on Presidents & Pandemics have to Say?

Max Skidmore, an expert on U.S. presidents, as well as my colleague and fellow author on this blog has written a book entitled Presidents, Pandemics, and Politics. Like so many other experts who tried to tell us what was likely to happen, Professor Skidmore presciently wrote this in 2016:

Presidents and Pandemics will argue that we must learn from past experience – mistakes and successes – in preparation for the future, and that future preparation vital to the maintenance of civilization, here and elsewhere. As critical as terrorism is in the modern world, including bioterrorism, an even greater threat comes from natural causes. It will be necessary to overcome the tendency to respond only to the most dramatic danger – the obscenities, say, of a scowling enemy decapitating a helpless captive, attacking innocent school children, or snarling evil intent that might take place here – as opposed to preparation also for what assuredly will take place here: ever more virulent pandemics.

Max J. Skidmore, Presidents, Pandemics, and Politics, New York: Palgrave Macmillan.

The U.S. Nursing Home System Was Warned and Didn’t Pay Heed to the Warning: That is Inexcusable

There appears to have been no preparation – no set of guidelines in place and enforced – to deter the rate of COVID-19 fatalities that occurred in U.S. skilled nursing facilities. If providers and agencies charged with regulating them didn’t know about guidelines for preventing mass fatalities due to a pandemic, they should have known.

Officials in Hong Kong knew about the devastation wrought by the 2003 SARS outbreak and took steps to prevent it from happening again. They issued a set of guidelines which required the following: (1) All facilities have an infection control officer, (2) Conduct annual outbreak drills, (3) Have a permanent 1- to 3-month stockpile of personal protective equipment (PPE) use, and (4) Establish visitation rules that address hygiene and PPE use, and procure technology to facilitate communication with families in case of an outbreak. Provisions were also made to externally quarantine infected residents and staff. (See: George A. Heckman, MD, et al., “Proceedings From an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes From Long-Term Care,” JAMDA, 28 April 2021, p. 2)

Seven Hundred and Sixty skilled nursing facilities in which 76,673 patients are ensconced are located in Hong Kong. It appears that approximately 30 patients in these facilities died because of COVID-19. In the U.S., it was not uncommon for a single facility to have 30 fatalities (e.g. Riverbend Rehab and Care in Kansas City Kansas owned by the Ensign Group, which had a phenomenally good year financially during 2020). Companies such as Life Care Centers of America, the Evangelical Lutheran Good Samaritan chain, and the Ensign Group had multiple facilities with 30 or more deaths. Fifty patients were killed in the Life Care Care Centers facility in Farmington, New Mexico, but there were many others in which excessive deaths occurred.

If There is No Accountability, the Next Natural Disaster in the Form of a Virus Will Result in Mass Fatalities of Institutionalized Skilled Nursing Patients

These days we are not hearing a call for a commission or even a strong move on capitol hill for serious investigative hearings. That is horrifying. The nursing home industry was well rewarded financially, but failed to discharge its responsibilities to care adequately for patients. My colleague Professor Charlene Harrington and I have conducted in depth research into the financial performance of publicly listed corporations deriving their revenue from public funds. They did quite well during 2020 and have as of yet not been called before congress to answer for their performance during 2020. We will continue to conduct that research and disseminate the results. (see: (See: Kingsley DE, Harrington C. “COVID-19 “Impact on publicly traded nursing home companies,” J Am Geriatr Soc. 2021; 1-4. https//doi.org/10.1111/jgs.17288.

Dave Kingsley