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Column: Here's one key reform that can fix U.S. healthcare

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Column: Here's one key reform that can fix U.S. healthcare

For more than 50 years, as the economics of American healthcare and health insurance have evolved, one theory has persisted, unchanged: To promote better and more efficient medical treatment, patients must have “skin in the game.”

The idea is that requiring fees for doctor or hospital visits — through co-pays, deductibles and other forms of cost-sharing — will prompt people to think twice before seeking treatment for anything but a truly serious condition.

“On the question of whether patients should have to pay part of the cost of their covered medical care, our profession’s advice has been unequivocal,” health economists Liran Einav of Stanford and Amy Finkelstein of MIT wrote in their 2023 book, “We’ve Got You Covered: Rebooting American Health Care.” “Patients must pay something for their care, otherwise they’ll rush to the doctor every time they sneeze.”

Among all advanced industrial countries, the U.S. goes furthest in using premiums, copays, and deductibles to influence access to care.

— Merrill Goozner, STAT

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Einav and Finkelstein own up to having “preached the gospel” of skin-in-the-game “to generations of students.”

Now here’s their punchline: “We take it back.”

To healthcare reformers such as single-payer advocates Adam Gaffney, David U. Himmelstein and Steffie Woolhandler, the confessional by Einav and Finkelstein “may signal an encouraging shift in elite opinion, at least among economists,” as they wrote recently in the New York Review of Books.

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Others have begun to take notice. “Among all advanced industrial countries, the U.S. goes furthest in using premiums, copays, and deductibles to influence access to care,” the veteran healthcare journalist Merrill Goozner observes. “It is time to put an end to this failed experiment.”

Yet the imposition of financial obstacles to limit access to care still exerts a powerful influence on healthcare policy in the U.S. In part, this is because it makes sense, superficially. The mantra goes: “If you want less of something, tax it more.” So it has a built-in appeal to government budget hawks and corporate executives who want to reduce healthcare spending.

For some, there’s a moral component — why shouldn’t people take personal responsibility for their own health, whether by smoking and eating less or paying for healthcare partially out of their own pockets, even if they have to be forced to make treatment choices based partially on their out-of-pocket costs?

Then there’s the empirical evidence: It’s true that the higher the co-pays and deductibles, the less medical care people seek, on average.

The seminal study on this topic was Rand’s Health Insurance Experiment, reported in 1981. Starting in 1971, Rand recruited 2,750 families — 7,700 individuals — slotted randomly into five groups: One was offered free care, three groups were offered different levels of cost-sharing, and the fifth was placed in a nonprofit HMO.

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Rand found that the groups with cost-sharing made one or two fewer physician visits a year and had 20% fewer hospitalizations than the group with free care. Their dental visits, prescriptions and mental health treatments were also lower. Unsurprisingly, they spent less on healthcare.

The initial findings seemed to validate the skin-in-the-game theory. As Rand continued reporting out the results over the next few years, however, air began to leak out of the balloon.

It became clear that although the cost-sharing subjects cut back on ineffective or unnecessary care, they also cut back on effective and necessary treatments. The reduced utilizations, Rand found, occurred because the subjects decided to delay or forgo treatments, possibly inadvisedly. Once they initiated care, the effect of cost-sharing dropped away, as the patients ceded their decision-making to their healthcare providers.

Some decisions weren’t affected at all by cost-sharing. “The proportion of inappropriate hospitalizations was the same (23 percent) for cost-sharing and free-plan participants, as was the inappropriate use of antibiotics,” Rand reported. Nor did cost-sharing prompt subjects to seek out higher-quality care; the general quality of outpatient and dental care was “surprisingly low for all participants.”

Although Rand found “no adverse effect on participants’ health” from the reduction in services prompted by cost-sharing, the free plan led to better healthcare for plan members in four categories: improved control of hypertension, better vision care, better dental care for the poorest patients, and fewer serious health symptoms for the poorer patients, including less chest pain when exercising and fewer episodes of loss of consciousness.

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Once cost-sharing became a standard element of American health insurance, Gaffney, Himmelstein and Woolhandler write, “the consequences were dire.”

The Heritage Foundation developed a model combining extreme deductibles and tax-advantaged savings accounts to pay the out-of-pocket expenses, which Heritage argued would “transform patients into prudent consumers.” The high-deductible/health savings account model was enacted into law, but plainly has failed to create an army of prudently cost-sensitive patients.

Co-pays and deductibles became permanently etched into employer-sponsored health plans. When the initial Rand findings were published, report Gaffney, Himmelstein and Woolhandler, only 30% of private health plans had a deductible for hospital stays; today 90% of workers with employer plans have annual deductibles averaging $1,735 per participant. Conservative governors and legislatures have tried to impose cost-sharing fees on patients in Medicaid, the nation’s healthcare program for low-income households.

And, of course, the cost-sharing revolution has utterly failed to control U.S. healthcare costs or bring about a healthier nation. Per capita healthcare spending in the U.S. has risen from about $350 in 1970 to $14, 470 in 2023. In inflation-adjusted terms, it has increased nearly sevenfold.

As for health outcomes, of 13 wealthy countries tracked by the Peter G. Peterson Foundation, the U.S. spends the most per capita by a wide margin and scrapes the bottom of the barrel on outcomes — the worst average life expectancy, worst infant mortality rate, worst rate of unmanaged diabetes, worst maternal mortality and nearly the worst heart attack mortality.

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Obviously, the American healthcare system has many flaws other than its reliance on cost-sharing. But all its flaws are related in some way to its economic structure, which has produced legions of uninsured and underinsured people, as well as crushing medical debt for millions. (On Tuesday, the Consumer Financial Protection Bureau made final a rule requiring medical debts to be removed from consumers’ credit reports. But the debts still remain.)

In recent years, the U.S. has started to get its arms around the uninsured crisis. That’s largely due to the 2010 Affordable Care Act, which has brought access to Medicaid and subsidized health plans for about 42.5 million people. The uninsured rate fell from nearly 18% (or 46.5 million people) in 2010 to 9.5% (25.3 million) in 2023.

Can these gains be advanced and sustained? The incoming Trump administration doesn’t present grounds for optimism. In his first term, Donald Trump and his acolytes worked tirelessly to undermine the ACA and Medicaid. The number of uninsured rose to 28.9 million in 2019 from 26.7 million in 2016.

It would surprise no one if the new administration takes a hands-off approach to the increasing corporatization of healthcare, including the takeover of hospitals and nursing homes by penny-pinching private equity firms and the pushing of more Medicare enrollees to join private Medicare Advantage plans, which have become known for costing the government more than traditional Medicare, and for profit-seeking through claim denials.

Still, it’s the installation of cost-sharing as a medical management tool that harms people day in and day out. That the tool has never fulfilled its promise doesn’t seem to faze policymakers. On the surface, after all, it should work, shouldn’t it?

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How Google’s 32-million mosquito project could change California’s battle against dengue

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How Google’s 32-million mosquito project could change California’s battle against dengue

Google took internet searches to the next level. Could it do the same for mosquito control?

The Silicon Valley-based tech giant is seeking to release up to 64 million sterilized male mosquitoes in California and Florida over two years, according to a notice in the Federal Register. It’s part of an ambitious effort to curb the diseases the insects spread.

Google says it can harness technology to optimize a concept that’s been around for decades, but hasn’t been successfully scaled with mosquitoes to rein in disease.

For example, the process often involves separating the insects by sex to isolate the males. Currently, that’s done manually and can be time consuming. Google says it’s “developing new technologies that combine sensors, algorithms and novel engineering to take advantage of unique aspects of mosquito biology to quickly and accurately sort males from females.”

The company also says it’s building software and monitoring tools to guide releases of sterile males, and its scientists and engineers are creating sensors, traps and software to decide which areas need to be treated and treated again.

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Called Debug, the project targets Aedes aegypti mosquitoes, which are native to Africa but have infiltrated nearly half of California’s counties since first being detected in the state in 2013. Not only do they drive residents nuts with itchy bites, but they can carry a number of potentially serious diseases, including dengue, Zika, chikungunya and yellow fever.

The plan is to infect males — which don’t bite — with a bacteria called Wolbachia, which effectively renders them sterile. They are then released to seek out wild females and mate. Females will lay eggs but these won’t hatch, which experts say drives down the population over time.

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There are other methods to sterilize male mosquitoes. Vector control districts serving Los Angeles, Orange and San Bernardino counties have irradiated males and released them in recent years.

Early results are promising. Two neighborhoods treated by the Greater Los Angeles Vector Control District saw a more than 80% reduction in the female Aedes aegypti population in 2024 and 2025.

But as the Greater L.A. district seeks to expand its operations, cost poses a problem. Last year, business owners signaled they weren’t willing to shell out more every year to make it happen. District officials are still hoping to sway them.

If Google moves forward, it wouldn’t be the first time it has been involved in such an effort. In 2018, the company conducted a large-scale trial in Fresno County, releasing 14.4 million Wolbachia-infected males in three neighborhoods.

“At peak mosquito season, the number of female mosquitoes was 95.5% lower in release areas compared to non-release areas, with the most geographically isolated neighborhood reaching a 99% reduction,” a 2020 paper reported.

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Google has applied for a permit from the Environmental Protection Agency to carry out the releases in California and Florida, for which the federal agency is currently seeking comments before deciding whether to grant approval.

The company aims to release up to 16 million Wolbachia-infected males in California, and the same in Florida, per year for two years, the Federal Register announcement said, for a total of 64 million.

Urgency to tamp down the invasive mosquito population in California has increased since 2023, when the state logged its first locally acquired dengue cases — meaning people were infected in their communities, not while traveling. The following year, the number of locally acquired cases ballooned to 18, with 14 of them in Los Angeles County.

A study published last week in “The Lancet Regional Health — Americas” found that approximately 18.2 million Californians — primarily in the Central Valley, L.A. and San Diego areas — live in regions where conditions are probably suitable for local dengue transmission.

“Under moderate scenarios of climate warming and urban expansion, an additional 4.1 million residents may be at risk by mid-century,” according to the study led by UC Berkeley’s Lisa Couper. Researchers note the current and future risk of transmission remains low except during summer in the Central Valley and Southern California.

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“I’m pretty much in favor of whichever [sterile insect technique] approach gets us the disease prevention and nuisance control we need and at the lowest price,” Susanne Kluh, general manager of the Greater L.A. County Vector Control District, said in an email.

She said her district went with radiation because it was the only approved technique when they wanted to launch their pilot, and that it’s “also the only one where some company does not make a profit in the middle.” However, she wouldn’t rule out using Wolbachia if it turned out to be the most affordable option.

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In a first for the country, voters in Monterey Park ban data centers

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In a first for the country, voters in Monterey Park ban data centers

Residents of Monterey Park voted overwhelmingly to ban data centers on election day, making the San Gabriel Valley city the first in the nation to do so by public vote.

As of Wednesday, 86% of votes were in favor of Measure NDC, the city ban, according to the Los Angeles County registrar-recorder/county clerk.

Other cities and towns have passed moratoriums on data centers, as a wave of opposition sweeps the country. But the Monterey Park vote can only be overturned by another ballot measure, making it the most permanent data center ban in a jurisdiction.

Monterey Park’s City Council had already banned data centers by ordinance, after a proposed 247,000-square-foot data center met an outpouring of public anger and concern. The developer withdrew that plan.

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That facility would have been less than 500 feet away from the nearest home, and would have used three times the electricity of the entire 60,000-person city. Residents said it would have caused noise and air pollution and driven up electricity rates.

“This ensures long-lasting protections for current and future generations,” Amy Wong, co-founder of the group San Gabriel Valley Progressive Action, said of the vote. “It means that future city councils cannot overturn a data center ban, even if data center developers wanted to spend money to fund pro-data center candidates.”

The measure had no formal opposition. The developer of the proposed facility, investment firm HMC StratCap, said it wouldn’t engage in the ballot fight when it withdrew in March.

The Data Center Coalition, an industry trade group, expressed disappointment in the vote.

“It sends a signal that the area is closed for business, both for data centers and for other significant economic development projects,” state policy director Khara Boender said.

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“It deprives local residents of the opportunity to compete for jobs and investment, while also causing the area to relinquish substantial long-term economic investment, high-wage jobs, and critical tax revenue to neighboring areas or other states.”

SGV Progressive Action worked with hyperlocal groups including No Data Center Monterey Park to rally support for the measure.

The group is now focused on stopping data center proposals in the City of Industry and fighting a move by City of Industry, Santa Fe Springs, Vernon and City of Commerce to welcome data centers and other industry with fast-tracked permitting and tax incentives.

City of Industry, in the San Gabriel Valley, and Vernon, south of downtown L.A., are primarily industrial areas, each with around 300 permanent residents. They are employment centers, and tens of thousands of workers commute in daily.

There has been little vocal opposition to data centers among the few residents of these cities. Wong said the protest is primarily coming from the surrounding neighborhoods.

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“If a data center gets built in City of Industry, residents across the region would bear the brunt of pollution and increased utility costs,” Wong said, noting that it is surrounded by 16 other cities and unincorporated communities.

Data center proposals have been limited in California compared to Virginia, Texas, Georgia, Illinois and Arizona, which sit at the center of a recent boom in hyperscaler facilities to power artificial intelligence.

California has the third-most data centers in the country, with 300, but high electricity rates, expensive land and regulatory hurdles mean that fewer, and smaller, facilities are currently planned than in other hotspots.

That doesn’t mean opposition hasn’t been fierce. In Coachella and Imperial County, residents are showing up in droves to protest local proposals.

In the San Gabriel Valley, Montebello, El Monte and Baldwin Park have all enacted temporary moratoriums, and Alhambra recently banned data centers as part of a zoning code update.

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Wong said she hoped the ballot measure vote would galvanize the opposition. “The vote is a testament to the people power of our region,” she said. “Our region is worth protecting, and we won’t let data centers determine our future.”

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Rent-hike ban to protect fire victims ends despite gouging concerns

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Rent-hike ban to protect fire victims ends despite gouging concerns

A rule intended to prevent rent gouging in the wake of the Eaton and Palisades fires has lapsed in Los Angeles County, possibly exposing some renters to hikes.

The executive order that blocked rent increases was issued by Gov. Gavin Newsom amid the devastating wildfires last year. Under the order, landlords couldn’t increase rents by more than 10% above their prefire levels.

The rule, which was supposed to be temporary and was repeatedly extended, ended Friday after a vote to extend it again failed to garner enough votes. Supervisor Lindsey Horvath, whose district includes Pacific Palisades, sounded the alarm in a motion to extend price protections that failed to pass at the Board of Supervisors’ May 19 meeting.

“These price gouging protections continue to be necessary as construction and rebuilding continue, and as thousands of people remain displaced,” the motion said. “Families which signed short-term leases could face drastic price increases of 50% or more without further price gouging protection.”

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Los Angeles County is home to more than 1 million rental properties, though not all of them needed protection from the new rule. There are already stricter rent increase caps for many residences, depending on the location, type and age of the building. Despite the rent control in the region, the people of Los Angeles pay among the highest rents in the country.

It is uncertain whether renters will face rapidly rising rents now that the protection has lapsed. But some real estate experts and policymakers said there was no need for the temporary rule that was part of the governor’s state of emergency.

Supervisors Kathryn Barger, Janice Hahn and Holly Mitchell abstained from voting on the motion to extend the protection, while Supervisors Hilda Solis and Horvath supported it.

“I abstained because I did not see sufficient evidence to justify extending this emergency ordinance, nor did I see evidence to eliminate it entirely,” Hahn said.

Barger’s office said she supported allowing the protections to sunset while waiting to see whether new information emerged.

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“Market data already shows countywide rents are only about 2% above pre-emergency levels and rental inventory has grown,” Barger representative Helen E. Chavez Garcia said. “The Supervisor is also mindful of the burden these ongoing protections place on small property owners throughout the county.”

Mitchell did not immediately respond to a request for comment.

There haven’t been steep rent hikes in neighborhoods within three miles of the Palisades fire, according to a Times analysis of data from Zillow, the property listing company.

In ZIP Codes within three miles of the Palisades fire, rent increased 4.8% from December 2024 to April 2025. In areas around the Eaton fire, which destroyed swaths of Altadena, rent jumped 5.2% in the same period.

In L.A. County, ZIP Codes farther from the fires saw only about a 2% increase.

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A landlords representative, Jesus Rojas of the Apartment Owners Assn. of Greater Los Angeles, told the supervisors during public comment at the meeting that the county’s rent-gouging rules have “long outlived the emergency they were intended to address” and are now being “wrongfully used to harm thousands of rental housing providers throughout the county.”

“There is no proof that multifamily rental housing providers are hugely increasing rents for impacted homeowners,” Rojas said.

Indeed, there are strong signs that the property market in the Los Angeles area has at last begun to cool.

L.A. metro-area rent prices recently fell to a four-year low, with the median rent slipping to $2,167 in December.

Meanwhile, condominium sales had their slowest start of the year in decades. Condo sales in Los Angeles have plummeted to a 20-year low, with fewer than 2,000 units sold in January and February — the worst start to the year since 2005.

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Newsom defended the price-gouging protections shortly after they went into effect.

“In the days following the Los Angeles firestorms, we worked quickly to protect Los Angeles survivors from any form of exploitation,” he said in February 2025. “The state has the tools in place to not only block price gouging during this emergency, but also to prosecute bad actors.”

The Los Angeles County Department of Consumer and Business Affairs said it received more than 2,000 complaints after the fires, alleging that retailers and landlords were taking advantage of people put in hardship by their losses, and sent out more than 2,000 cease-and-desist letters to businesses and landlords for alleged price gouging, said Morine Merritt, who oversees department investigations into consumer and real estate fraud.

“Close to 90% of the complaints that we received involved allegations of rent increases,” Merritt said in an interview. Now that the fire-related protections have expired, existing laws and “regular market conditions determine price increases for goods and services, including rents,” she said.

Crackdowns on fire-related rent gouging have been rare, said Chelsea Kirk of the activist organization the Rent Brigade, which analyzed L.A. County’s rental market in the year after the fires. It reported 18,360 potential examples of price gouging in listings but said that few lawsuits had been filed by authorities so far.

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Last week, Rent Brigade announced what it said was the first private civil lawsuit brought by a family that claimed to be rent-gouged in the aftermath of the wildfires. Plaintiffs Randall and Candy Renick, whose Altadena home was damaged, said they were charged nearly three times the maximum permitted rate for nearly 10 months. They seek restitution of $96,000 plus civil penalties and attorneys’ fees.

The rental market has probably stabilized since the fires, Kirk said, but other families may still be “locked into illegal rents” that they agreed to pay when they were in a rush to find housing after they were displaced.

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