Compassion in an age of anxiety and disillusionment / Review by Lital Khaikin

Originally published in Canadian Dimension on February 2, 2023

Gabor Maté’s new book explores questions of survival and thriving in a traumatized and and (re)traumatizing society

Published in September 2022, Canadian physician and author Gabor Maté’s new book, The Myth of Normal, is a rich examination of the conditions that lead not only to individual illness, but to the cultural normalization of stress, emotional repression, alienation, and disenfranchisement. Through his therapeutic practice of ‘compassionate inquiry,’ Maté shows how psychological trauma is exacerbated by cultural norms and capitalism, and emphasizes a curiosity toward individual circumstance as a way of understanding and healing core psychic wounds.

The Myth of Normal: Trauma, Illness and Healing in a Toxic Culture
Gabor Maté with Daniel Maté
Knopf Canada, 2022

Accessibly written in collaboration with his son Daniel Maté, The Myth of Normal questions and dismantles notions of ‘normalcy,’ interrogating the factors behind the apparent rise of trauma-related illnesses and the oft overlooked social and economic circumstances that can make us sick.

The theme of disillusionment anchors The Myth of Normal, and the book signals in many ways an evolution from Maté’s earlier works including In the Realm of Hungry Ghosts (2008), a study of the addiction and opioid crisis in Canada. In that acclaimed earlier work, Maté makes a clear link between economic precarity, social disenfranchisement, and the stigmatization of difference with an individual’s predisposition to opiate addiction. As he wrote: “The question is never ‘Why the addiction?’ but ‘Why the pain?’”

Where Maté’s extensive study of the social roots of the opioid crisis ended, however, his new book picks up, tying in common threads with his 2003 work When the Body Says NoThe Myth of Normal broadly explores the consequences of the “mind-body bifurcation,” or the dissonance between the mind’s narrative and the body’s sensed reality. This division is encouraged by social conditioning that traps people in traumatized patterns and maladaptive coping mechanisms based on emotional repression and denial.

Reiterating his past insights, Maté shows how chronic illness and immune disorders from cancer, multiple sclerosis, and ALS are often symptomatic of emotional repression and accumulated stress. The urgency of Maté’s arguments is clear as Canada’s health care system sees intensifying privatization, while social support systems become increasingly difficult to access.

As Maté writes, it is the “willingness to be disillusioned” that serves as a point of departure for bringing trauma awareness into medicine, legal systems, and educational environments in an intentional and systematic way.

“The personality is an adaptation”

While Maté emphasizes compassionate inquiry as a core element of his therapeutic practice, The Myth of Normal proposes curiosity as the foundation of a caring society. Curiosity, by nature, embraces the unknown. Its absence shapes a society where individuals are not in dynamic conversation with their environments and with unknown ‘others,’ and relate to one another through an ‘identity-by-template’ formula.

Without curiosity, we may become emotionally repressed, resentful, and disempowered. This is exacerbated when selected fragments of our lives are uploaded to social media platforms that are optimized based on unattainable ideals, and which are designed to capitalize on our most vulnerable insecurities.

Maté explores how dependence on external self‐presentation is an extension of neuromarketing, the normalized corporate strategy of targeting the pleasure response, which is often foundational to the algorithms that shape the content and behaviours of internet communities.

Indeed, social media is the ultimate marketplace for the self as product. It is geared towards optimizing the performance of self, of one’s visible social networks, and of a person’s aesthetic, gestures, expressions, and tonality. The result is a closed system where the self that best matches an algorithm displaces multiplicity and authentic diversity, convincing people into desiring to be anything but themselves. This creates a tension between the perception of self and an uncanny absence of self. As Maté writes, citing Trappist monk and poet Thomas Merton, this results in “living always in somebody else’s imagination” within a society “whose whole policy is to excite every nerve in the human body and keep it at the highest pitch of artificial tension.”

Contrary to notions of a fixed self, The Myth of Normal emphasizes permeability and changeability. “It is closer to the truth to think of the personality as a recurring phenomenon than a fixed or permanent one,” he writes, “much like the way individual movie frames projected at rapid speed create the optical illusion of a single, continuous narrative.”

This principle, however, doesn’t fit capitalist incentives for profit that trap us within states of insecurity and precarity, and which engender a perception of inner lack. Feelings of self-completeness, the absence of desperate co-dependence, and the fluidity of self-expression are much harder to influence and control—and are not profitable for industries that depend on keeping people stuck in their traumas, scrutinizing and fixating on their shortcomings.

But it also poses a challenge when a person’s sense of self is shaped by the narrative and scars of trauma, and disruptive traumatic response is internalized as an immutable part of one’s identity. Maté has addressed this in his previous writings, showing how addiction (a form of traumatic response and coping) can become an anchor for identity, with the addict seeing no other possibility for existence: “No matter how much he may acknowledge the costs of his addiction, he fears a loss of self if it were absent from his life. In his own mind, he would cease to exist as he knows himself.”

In an honest reflection on his own evolution in therapeutic practice in a chapter entitled “An Inaccurate Map of Our Pain,” Maté acknowledges the potential benefits of pharmacological approaches to treating symptoms of trauma, but bases the heart of his new book on healing the root of suffering rather than medicating. “In my medical practice I became something of a Prozac booster, succumbing to the error of looking for pathology where there was only everyday unhappiness,” he writes. “I am primarily interested in what will promote the healing of the psychic wounds the ongoing traumatic patterns represent.”

As in Maté’s previous books, The Myth of Normal includes many examples and stories of patients and individuals Maté has encountered to support his emphasis on psychic wounds within therapeutic practice in order to treat the root causes of suffering. Recounting the story of a young doctor in the section “A Physician Heals Herself,” Maté draws a portrait of a woman who systematically repressed her emotions and tolerated harassment at work. It took being admitted to a hospital for coronary distress and pre-cancerous cervical abnormality, and later becoming suicidal, to confront the abuse the interpersonal stress was inflicting on her emotional self.

Maté shows how these superficial symptoms can be addressed through a change of environment, with what appears to be a facet of personality or an unsolvable crisis transforming in conditions that are conducive to temperament and thriving.

Similarly, in the popular book Attached, authors Amir Levine and Rachel Heller write how elements of seeming pathology, which they reframe as chronic activation of attachment systems, can be understood and transformed by changing one’s environment. Through numerous examples of relationships with conflicting needs, the authors demonstrate how the absence of what Maté might call ‘compassionate inquiry’ within a relationship creates a defensive environment that shows fundamental lack of care for wellbeing.

Levine and Heller describe a relational framework that, rather logically, sees behaviours as interdependent and the conditions for wellbeing as being a product of reciprocation in their environments. While seemingly obvious, such thinking is not as normalized as punitive judgements of individuals. Crucially, the authors of Attached don’t assign moral judgement or prescribe doom to any attachment pattern or combination thereof. Rather, they emphasize the plasticity of behaviour through awareness, allowing people to retain dignity within confusion, and illustrating how different approaches can either contribute to perpetuating or resolving traumatic patterns.

Dr. Gabor Maté. Photo from Flickr.
An inherited legacy

The Myth of Normal offers many segues into domestic and global political issues, and many of them relate to repression and punishment of difference, and the internalization of shame as a mode of social control. In particular, Maté explores the profound consequences of emotional repression in intimate and social relationships due to a fear of risking non-compliance, and of disappointing or being cut off from a caregiver or authority. But as trauma theory and its vocabulary gain mainstream acceptance, the knowledge of traumatic response and its manifestations can also be used to discredit and exert coercive control over individuals, and to invalidate their criticisms—be it in the bedroom, the workplace, or in the geopolitical theatre.

In his chapter “A Template for Distress,” Maté describes the phenomenon of self-abandonment in the face of threats as ‘hypnotic passivity,’ which is programmed through punitive measures for non-conformity, protest, and spontaneity in ways of being. “As citizens in ostensibly democratic countries, we have free will, up to a point—but in practice that freedom rarely strays beyond the frontier of what is socially acceptable,” he writes. “Not daring to rock the boat, we risk sinking with it.”

In Sara Ahmed’s acclaimed book Complaint! (2021), the feminist theorist’s analysis of how institutional power in academia protects itself by discouraging, suppressing, disappearing, or even co-opting complaint shows the extent of normalization around guilt and shame for being a “trouble-maker” or “feminist killjoy.” Illustrating this phenomenon in an interview with The Paris Review, Ahmed described how institutional power pathologizes complaint and capitalizes on the internalization of shame to target individuals rather than confronting embedded, systemic problems: “A lot of people talked to me about how when they tried to make complaints, it was often the diversity agenda that would be used against them—as if they weren’t doing this the right way, as if they weren’t being appealing enough, as if by even using certain words they were trying to make life difficult for other people, including other minoritized staff.”

The relational nature of trauma explored in The Myth of Normal also recalls the cautionary angles on trauma’s place in social institutions raised in the book The Empire of Trauma (2009) by Didier Fassin and Richard Rechtman. Using France’s immigration system as an example, Fassin and Rechtman offer a nuanced critique of treating trauma as an unassailable moral category within systems that are already antagonistic toward vulnerable and marginalized people like refugees, veterans, and survivors of abuse and torture.

Reflecting on how the category of trauma has moved from clinical psychiatry into “everyday parlance,” the authors are wary of how, outside of a clinical context, the category of trauma gives a sense of social validation and status which are not otherwise afforded by society. “[T]he truth of trauma lies not in the psyche, the mind, or the brain,” they write, “but in the moral economy of contemporary societies.”

Fassin and Rechtman criticize the ideological underpinnings of social infrastructures based on a lack of compassion, and the trap of a cynical era that demands performance of victimhood in order for suffering to be heard and validated, and thus as “an important indication of the way in which the tragic is understood in contemporary societies.”

Speaking with Canadian Dimension, co-writer Daniel Maté explained that The Myth of Normal makes a point of trying to reach those “who might not already be convinced” by trauma theory. His response echoes the challenge of creating a ‘new normal’ and unmaking myths presented in the book’s last chapter.

“There are medical practitioners who haven’t fully ‘lost their religion’ or become disillusioned entirely with Western medicine, yet there is a sliver of openness there,” he described in an email. “And then there are the real tough nuts: people deeply ensconced in academia or scientific institutions who might have a knee-jerk distaste for this project.

“Often there are culture-war aspects to this: some people distrust the ‘woke’ use of victimized identity as a cudgel to force compliance in others, particularly on the level of oppressed groups, and see coddling as a danger.”

The Myth of Normal is a comprehensive volume that ties in common threads from across Gabor Maté’s previous works, and connects a progressive therapeutic approach toward trauma with the social crises borne under capitalism. The humanitarian tone of the book and the inherent liberatory potential of trauma-informed social praxis are at the heart of building a world whose visible and invisible structures can be guided by compassion instead of fear.

At its heart, the arguments presented in the book encourage the possibility that each of us can play a redemptive role in one another’s life; nudging off the well-trod pathways of self-sabotage, transforming one another’s betrayed sense of safety and vulnerability, and allowing the possibility for just one thing, this time, to be different on the way to an authentic life. As Maté invokes by quoting Victor Hugo: “At intervals can be seen a glimpse of truth, the daylight of the human soul.”

Lital Khaikin is an author and journalist based in Tiohtiá:ke (Montréal). She has published articles in Toward Freedom, Warscapes, Briarpatch, and the Media Co-op, and has appeared in literary publications like 3:AM Magazine, Berfrois, Tripwire, and Black Sun Lit’s “Vestiges” journal.

Architects of Medicare Privatization: Congress, Biden and the CMS / by Sandra M. Fox

Photograph Source: Molly Adams – CC BY 2.0

Originally published in Counterpunch, December 30, 2021

It is easy and appropriate to target the private health insurance companies who earn excessive profits from the Medicare Trust Fund through Medicare Advantage plans, especially given the well-documented evidence of overcharging and fraud.

But it is essential that we remember that it has been the U.S. Congress and the Executive Office that promoted the privatization of Medicare, to varying degrees, since it was first signed into law by President Johnson in 1965 and enacted the following year.

In 2017 The Commonwealth Fund published “The Evolution of Private Plans in Medicare,” which detailed the increasing role in healthcare granted to private companies since 1966 through Acts of Congress and the Office of the President.   Privatization was boosted significantly by the Medicare Modernization Act of 2003, which–in addition to providing private drug coverage (with non-negotiable prices) through Medicare Part D–provided an alternative payment structure to private health insurers as a way to incentivize and increase their participation in the Medicare program.  And it worked; more health insurance companies decided to enter the Medicare “market” and labeled their plans “Medicare Advantage.”  Almost 50% of Medicare beneficiaries are now enrolled in private plans, compared to those in traditional Medicare.

There are many reasons why seniors and those with disabilities continue to enroll in traditional Medicare.  Traditional Medicare does not have restrictive provider networks and individuals can seek care from any provider in the country who takes Medicare.  Further, prior authorizations are not required, as they are in Medicare Advantage plans.  Delay and denial of care are hallmarks of Medicare Advantage plans–not traditional Medicare–as a way of increasing the profit margin of private companies.  However, delay and denial of treatment also mean worse health outcomes and an increase in premature death.   The Mayo Clinic has stopped accepting patients with Medicare Advantage plans and is encouraging patients to enroll in traditional Medicare instead.

Traditional Medicare has no profit; its administrative overhead is less than 2%, compared to 15% overhead and profit for Medicare Advantage plans.  As a result, traditional Medicare is less costly, while payments to Medicare Advantage plans are draining the Medicare Trust Fund, a fund workers pay into, as they do for Social Security.

Advocates for a national single-payer healthcare system in this country, often referred to as Improved Medicare for All, acknowledge the weaknesses in the current version of traditional Medicare.  While the federal government has allowed for perks to beneficiaries in Medicare Advantage plans, including free gym memberships and some (limited) dental and vision care, these benefits are not available to those choosing traditional Medicare.  Why not?  They are a clever way for private companies to increase enrollment in their plans, in addition to lowering their premiums, made possible through excessive payments received from the Medicare Trust Fund to private insurers.  So far, Congress has not expanded those benefits to beneficiaries in traditional Medicare, thus favoring for-profit companies.

The money is there to improve traditional Medicare and expand it to cover all residents of the United States, as substantiated by the Congressional Budget Office.  But many elected officials on both sides of the aisle will say otherwise and are compensated by private health insurers with handsome campaign contributions.

Meanwhile, the Center for Medicare and Medicaid Innovation (CMMI), under the Center for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS), was established as part of the 2010 Affordable Care Act (ACA).  According to its website,

“the CMS Innovation Center, through its models, initiatives and Congressionally-mandated demonstrations, has accelerated the shift from a health care system that pays for volume to one that pays for value.”

The ACA also allowed CMMI to make changes without Congressional oversight.  And CMMI is determined to reframe privatization as value-based care.

CMMI has been quietly contracting with for-profit companies to engage in “pilot programs” that insert middlemen into traditional Medicare without the beneficiary’s consent and often without their knowledge.  The Trump Administration, which launched the program, contracted with 53 for-profit middlemen called Direct Contracting Entities (DCEs).  The Biden Administration re-branded the program ACO-REACH (Accountable Care Organizations Realizing Equity, Access, and Community Health) and increased the number of corporate participants to 99.

These participants include private health insurance companies as well as private equity/venture capital firms, which can keep up to 40% of Medicare dollars in administrative costs and profits by “managing” patients’ healthcare.  The supposed goal is to lower costs through “value-based care.”  We already know that lowering costs in Medicare Advantage means delaying and denying care by requiring prior authorizations, as well as restricting provider networks.  Furthermore, an excellent analysis by healthcare policy experts Kip Sullivan, J.D. and James G. Khan, M.D., refutes the premise of CMS that Accountable Care Organizations will save money, given evidence of past performance.

The intended goal is the complete privatization of Medicare by 2030, as posted on the CMS website:  “All Medicare fee-for-service beneficiaries will be in a care relationship with accountability for quality and total cost of care by 2030.”  Starting January 2023, the number of ACO-REACH programs managing the care of traditional Medicare beneficiaries is slated to increase dramatically, from 99 to over 200.

The appointment of Elizabeth Fowler, Director of CMMI, whose past work in the private healthcare sector as Vice President for Global Health Policy at Johnson & Johnson and as Vice President of insurer Wellpoint (now Anthem), not only poses a huge conflict of interest.  It reflects the intention of many within the federal government to privatize healthcare.  During the Obama administration, Fowler assisted in the development and implementation of the ACA, which created the CMMI, the office she now directs.

Since Congress does not have oversight of CMMI, it will take an Executive Action by the President to eliminate the ACO-REACH program.  President Biden could do this with a stroke of his pen.

Healthcare advocates must recognize that the instruments of privatization are in the government’s hands and that CMMI, CMS, the Secretary of Health and Human Services, Members of Congress, and the President of the United States have been complicit for years in the privatization of a beloved public program, Medicare, and must all be held accountable.

What constitutes government accountability in healthcare?

There are those in Congress, as well as some healthcare advocates, who ascribe to a “bad actors” paradigm; i.e., if we can issue new rules, fine, and/or weed out the private companies that engage in Medicare fraud we will be doing our job in protecting the public.  Diane Archer, a long-time healthcare advocate and President of Just Care, writes on 12/21/22 that the current fines are grossly insufficient to de-incentivize corporations from committing fraud.  And she is right.

However, as Archer concedes in a March 2022 interview, private corporations in healthcare are following their profit-driven mission to maximize profits and satisfy their shareholders, not the public, and that an improved system of Medicare for All is the solution.

Don McCanne, M.D., another long-time healthcare advocate, writing for Health Justice Monitor on 12/22/22, comments that CMS’s new proposed regulations for Medicare Advantage programs are “camouflage for perpetuating” a “wealth-creating business model” and calls for the end of privatization in Medicare and Improved Medicare for All.

The majority of Americans favor a “single government program to provide healthcare coverage.”

Even in a county that voted overwhelmingly for former President Trump–rural Dunn County, Wisconsin–a referendum asking “Shall Congress and the President of the United States enact into law the creation of a publicly financed, non-profit, national health insurance program that would fully cover medical care costs for all Americans?” passed.

Whether it’s tax incentives for polluters, with EPA issuing fines for environmental degradation and health risks, or the federal government designing a system for the privatization of Medicare and CMS issuing fines to the profiteers, we need to reckon with our government’s history of working hand in glove with corporate interests, often at odds with the best interests of the people and the planet, and not compromise our own expectations and the demands we make of elected officials.  As McCanne wrote, the proposed regulations are indeed a means of perpetuating the status quo.  We need to get the middlemen out of healthcare, improve traditional Medicare, and expand it to cover everyone.

Sandra M. Fox, LCSW, is a psychiatric social worker who has worked in healthcare in southern West Virginia and Pittsburgh, Pennsylvania for over 40 years, was a co-founder of the Western PA Coalition for Single Payer Healthcare and is on the steering committee of National Single Payer.

    The Stealth Privatization of Medicare Is a Big Boon to Wall Street / by Matthew Cunningham-Cook

    via AFL-CIO

    The Biden administration recently expanded on Donald Trump’s efforts to privatize Medicare. Now patients are being assigned to new private plans without their consent, and private equity firms and major health care companies are the ones profiting.

    The Joe Biden administration’s recent entrenchment and expansion of the Donald Trump administration’s efforts to privatize Medicare is helping a shadowy set of big-business beneficiaries: private equity firms and major health care companies, including one that previously employed the government official overseeing the privatization plan, a new analysis from us shows.

    In April last year, the Biden administration contracted with fifty-three third-party companies to mandate privatized health care plans through Medicare. The resulting health care options are effectively Medicare Advantage plans, or private coverage offered through the national health insurance program for seniors and people with disabilities — but with one wrinkle: Patients are being assigned to these new plans without their consent.

    The fifty-three participating companies — called “direct contracting entities,” or DCEs — are allowed to offer benefits beyond traditional Medicare, like gym membership coverage. But as for-profit businesses that receive a set payment from Medicare no matter how much care they approve, these DCEs are incentivized to limit the care that patients receive, especially when they are very sick. The first DCEs were launched by President Donald Trump in 2019, and so far, at least 350,000 seniors have already been moved onto these privatized Medicare plans.

    Now, a new analysis by us of the fifty-three DCEs found additional cause for concern: fifteen of these entities, or slightly more than a quarter, are backed by private equity firms, which are known for extracting profits at the expense of workers, the environment, and even their own pension fund investors. The firms include big-name firms like the Carlyle Group, General Atlantic, Clayton, Dubilier & Rice, Benchmark Capital, and Warburg Pincus. What’s more, another fifteen DCEs are linked to big health care companies — including one with a direct connection to the Biden appointee in charge of the new privatized Medicare scheme.

    Wall Street’s encroachment into Medicare is the latest example of private equity’s aggressive expansion into health care, which has ranged from hospitals to ER doctor groups. In 2021, private equity managers deployed $172 billion in capital in the health care sector — nearly four times the total budget of the National Institutes of Health.

    Biden himself has lambasted the for-profit industry’s takeover of eldercare servicesnoting during his State of the Union address in March: “As Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up. That ends on my watch.”

    Biden apparently doesn’t have the same concerns about Wall Street’s growing role in Medicare — a development that could lead to higher medical bills for patients. The financial industry has already demonstrated its willingness to take a forceful approach to generating health care profits; private equity waged an aggressive campaign to derail legislation designed to stop so-called “surprise” medical bills, which formed a significant part of their hospital staffing firms’ bottom line.

    President Joe Biden delivers remarks to Department of Defense personnel at the Pentagon in Washington, DC, on February 10, 2021. (Lisa Ferdinando / US Secretary of Defense via Flickr)

    Now, as private equity muscles into privatized Medicare, industry lobbyists are likely to push for more generous payment structures that benefit for-profit firms at the expense of Medicare patients. The Medicare Payment Advisory Commission, an independent body that advises Congress on Medicare, hinted at this scenario while discussing private equity’s role in the Medicare Advantage space at an April 2021 hearing.

    “The end result might or might not be better for consumers, but I think that it does have an impact on Medicare payment policy,” said commissioner Pat Wang.

    Experts fear that the Medicare space could be especially vulnerable to Wall Street’s predatory approach.

    “We have lots of evidence from many other situations in which private equity puts profits before patients,” said Eileen Appelbaum, codirector of the Center for Economic and Policy Research and coauthor of Private Equity at Work: When Wall Street Manages Main Street. “They are looking for a place where it’s easy to make money — and it’s easy to make money when it’s the taxpayer footing the bill.”

    Big Players, Big Profits, and a Big Conflict

    While the DCE program was launched under President Trump, Biden expanded the effort in February under a new name: the Accountable Care Organization Realizing Equity, Access, and Community Health program, or “ACO REACH.” Now, hospital-backed for-profit health benefit programs are also allowed to automatically enroll Medicare patients into their health care plans.

    Like providers of Medicare Advantage plans, these new firms receive a set payment from Medicare for their offerings, supposedly to incentivize more holistic and better care. In exchange, these firms acquire Medicare patients in their plans — often  without the patients realizing what is happening.

    In March, we reported on how one Medicare beneficiary who was quietly assigned to a DCE initially misinterpreted a message she received about the shift as a health-related communication from her doctor — despite being an experienced health policy expert.

    Along with the fifteen private equity-backed companies, the list of approved DCEs the Biden administration released in April 2021 includes fifteen operations owned by health care giants, such as insurers Humana, UnitedHealth, and Anthem, the pharmacy chain Walgreens, and the dialysis provider DaVita.

    Experts say these connections raise serious questions about conflicts of interest. For example, the DCE program is being led by a little-known federal entity, the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center, headed by Liz Fowler — the former vice president of public policy for the insurer WellPoint, now known as Anthem.

    In response to our request for commenta CMS spokesperson said that Fowler was not involved in the approval process for DCEs. They additionally asserted that many of the entities identified by us are not private equity–backed because they are public companies.

    But several of these public companies have received substantial investments from private equity firms, also known as “private investment in public equity.” For example, while 1LifeHealthcare — a primary care provider that owns one of the DCEs, One Medical’s Iora Health — is publicly traded, the major private equity firm Carlyle Group owns more than 7 percent of its shares.

    Critics say Fowler has a history of crafting policy to help her private sector contacts.

    “Honestly this just seems to add to the pattern we’ve observed with Liz Fowler,” said Fatou Ndiaye, a research assistant with the Revolving Door Project, which monitors the revolving door between the public and private sector.

    Ndiaye pointed out that before she lobbied for WellPoint, Fowler worked for Senator Max Baucus (D-MT), where she helped draft Medicare Part D, a program critics said was a huge giveaway to the pharmaceutical industry because it created massive new drug benefits without controlling prices.

    After working for Wellpoint from 2006 to 2008, Fowler rejoined Baucus’s staff, where she helped draft a version of the Affordable Care Act (ACA) that excluded the public health insurance option promised by Democrats, resulting in huge profits and no public sector competition for private insurers.

    “A year after [ACA’s] passage, Wellpoint’s profits increased by 91 percent to $2.3 billion,” said Ndiaye.

    Private Equity Muscles In

    The fact that private equity now backs more than a quarter of all companies in the DCE space stands in stark contrast to the fact that private equity owns just 2 percent of all for-profit Medicare Advantage programs.

    While Medicare Advantage options have been criticized by health advocates because of their extremely high costs, the fact that private equity is focusing its attention on this new kind of nonvoluntary privatized Medicare scheme suggests that Fowler and the Biden administration could be setting the stage for substantially larger private equity involvement in the national health insurance program.

    Examples abound of problems arising when private equity takes over health care operations. Just last month, Buzzfeed News reported that BrightSpring, a group home operator acquired by private equity megafirm KKR in 2019, has since been plagued by serious problems at its group homes for people with disabilities, leading to residents being seriously injured and in some cases dying.

    The Carlyle Group, which has an ownership stake in OneMedical, the parent company of Iora Health, has a particularly disturbing history in health care. After Carlyle acquired HCR Manorcare, a nursing home chain, the company was plagued by serious lapses in standards of care until it went bankrupt eleven years later.

    Other private equity–backed operations approved for the new DCE program have major connections to the Democratic Party establishment. The private equity firm Warburg Pincus, which backs a DCE called Excelera, was cofounded by the father of current secretary of state Antony Blinken and boasts former Barack Obama treasury secretary Tim Geithner as its president.

    Laura Katz Olson, a professor at Lehigh University and author of the recently published Ethically Challenged: Private Equity Storms US Health Care, said that private equity’s role in Medicare privatization raises significant concerns.

    “If you understand the private equity playbook, the dangers are fairly obvious,” said Katz Olson. “They’re borrowing money so they have to pay off debt. They’re taking money into their pockets through fees. You would have to be a magician to keep up quality of care doing all of these things.”

    She added, “Private equity is bad for health care, period, so I can’t imagine that it would be good for Medicare Advantage. I’m actually in a state of surprise that they’re even thinking about it.”

    Jacobin, May 11, 2022,

    Wall Street moves to privatize Medicare / by Tim Wheeler

    via AFL-CIO

    SEATTLE—Rep. Pramila Jayapal, D-Wash., is leading the struggle to block medical insurance profiteers from privatizing Medicare, a scheme covertly launched by former President Donald Trump and continued in a new guise by the Biden administration.

    Jayapal sent a letter Jan. 5 to Health and Human Services Secretary Xavier Becerra and Medicaid Administrator Chiquita Brooks-LeSure urging the Biden administration to terminate the Trump-initiated scheme to shift Medicare beneficiaries to so-called “Medicare Direct Contracting Entities” (DCE), such as Aetna and Humana, without informing the recipients.

    “As you know,” Jayapal wrote, “the previous administration started Direct Contract Entities (DCEs) which are privately owned and controlled networks in which for-profit companies are paid monthly to cover beneficiaries’ health care. Any funds left over after it covers care are kept as profits, creating a perverse motive to decrease the quality and volume of seniors’ care.”

    She added, “These models ultimately aim to privatize traditional Medicare by funneling beneficiaries, without their knowledge, into a DCE.”

    DCEs, she continued, “pose a threat to patient care and outcomes due to the encroachment of profit-driven organizations on their care.”

    More than 50 other members of the House, all Democrats, co-signed her letter.

    Physicians for a National Health Program (PNHP) denounced the Trump DCEs, circulating a petition signed by more than 13,000 physicians and other health advocates blasting the scheme to privatize Medicare.

    The pressure was so strong that the Center for Medicare Services (CMS) announced a few days after Jayapal’s letter a freeze on acceptance of new applications to the DCE program. CMS also announced that the DCE program will be replaced Dec. 31, 2022, by a new program, ACO REACH (Accountable Care Organization-Realizing Equity, Access, and Community Health).

    Critics charged the new plan was no better than Trump’s DCE.

    Jayapal pointed out that the 53 private equity firms and insurance companies that currently provide health care coverage “already take large profits from other healthcare ventures and will likely do the same from Medicare DCEs at the expense of patient care.”

    She cited Medicare Advantage plans that have invented “upcoding,” the practice of adding extra diagnosis codes to patient charts in order to squeeze more money from the Medicare Trust fund to increase their profits.

    “This scheme already costs the U.S. government $10.6 billion per year, and with the addition of traditional Medicare beneficiaries into this scheme those costs will almost surely rise.”

    DCEs are projected to spend as little as 60% of the taxpayer dollars they receive on care, allowing them to keep up to 40% as profit….” By contrast, the administrative costs of non-profit traditional Medicare are 1.5%, leaving 98.5% of every Medicare dollar for patient care.

    Jayapal requested a meeting with Becerra and Brooks-LaSure to “stop the expansion of these Direct Contracting Models and oversee the sunsetting of these programs.”

    While all Republican members of the House and even a majority of Democrats refused to sign her letter, the fightback against Medicare privatization is moving ahead.

    Here in Jayapal’s home district, Seattle, Puget Sound Advocates for Retirement Action (PSARA) has launched a grassroots campaign to stop Medicare privatization. PSARA Co-Presidents Jeff Johnson and Karen Richter sent out a letter, saying:

    “For decades, Wall Street has tried and failed to privatize our Social Security. Now they are trying to privatize traditional Medicare on top of the already existing Medicare Advantage plans. The financial rewards for achieving this goal are enormous.”

    They add, “The Trump administration has opened the door to complete privatization of Medicare. The Biden administration has furthered the Trump lead by continuing the Direct Contracting Pilot program until the end of 2022 and then beginning a new program labeled ACO REACH, which is privatization of traditional Medicare with a new name – Hands Off our Medicare!”

    Tim Wheeler estimates he has written 10,000 news reports, exposés, op-eds, and commentaries in his half-century as a journalist for the Worker, Daily World and People’s World. Tim also served as editor of the People’s Weekly World newspaper. He lives in Sequim, Wash., in the home he shared with his beloved late wife Joyce Wheeler. His book News for the 99% is a selection of his writings over the last 50 years representing a kind of history of the nation and the world from a working-class point of view.

    People’s World, April 6, 2022,

    Biden administration bent on privatizing traditional Medicare / by Diane Archer

    There appears to be little light any more between corporate health care and government health care or even between government health care-speak and corporate health care-speak. In the latest government push to privatize traditional Medicare–“ACO REACH”–insurer and investor middlemen will responsible for assuming risk and paying claims. The Biden administration claims its goal is “value-based care,” though decades of evidence show that corporate middlemen drive up costs and do not deliver value for patients.

    What’s happening? The Biden administration is continuing a Trump administration experiment to pay middlemen–often entities with no meaningful medical expertise–a flat fee per patient to “manage care” for people in traditional Medicare. The administration just renamed the “Global Professional Direct Contracting” experiment–which works like Medicare Advantage–ACO REACH. It will privatize traditional Medicare by turning over “care management” read “money management,” to investors and insurers.

    Who will be in the experiment? People with Medicare whose primary care physicians are working for a middleman that contracts with the Centers for Medicare and Medicaid Services as part of “ACO REACH.”

    What’s the value to patients? If you look at the role insurer middlemen play in Medicare Advantage, it is hard to see that ACO REACH offers any possibility of value to patients and easy to see huge risk. Given the scant data available in Medicare Advantage, no one can demonstrate value in the care patients receive. MedPAC, the government’s Medicare oversight agency, has never been able to assess care quality in Medicare Advantage plans because the plans have never given it complete and accurate information that would permit MedPAC to assess value. At the same time, government agencies have found widespread and persistent inappropriate delays and denials of care and coverage putting patients at serious health risk.

    ACO REACH will offer “care coordination,” but what does that mean?  The Center for Medicare and Medicaid Innovation (CMMI) claims the ACO REACH model is somehow going to ensure people in traditional Medicare have their care coordinated in ways that improve health outcomes. But, there is no evidence that people in managed care plans have better health outcomes than people in traditional Medicare. In fact, “care coordination” is often a euphemism for delayed care, less care, and referrals to low-cost providers, none of which is by definition a good thing. Primary care doctors will have financial incentives to minimize costs.

    Will ACO REACH promote health equity? CMMI also says it is promoting health equity through ACO REACH, but there’s no evidence to support that claim. Participants will need to have health equity plans. But health equity plans are far different from results and, so long as cost is a barrier to care, it’s hard to see how participants can reduce health disparities. It’s also hard to imagine how CMS will ensure compliance by participants with model requirements.

    Diane Archer has been helping people navigate Medicare and retirement issues for more than 25 years. Just Care is her latest venture, which she is volunteering her time to build and test. Diane is creating Just Care in order to share helpful consumer-friendly information and to promote the organizations doing the best work.

    JustCare, March 9, 2022,