Search the archive.

Small businesses are a huge sector of the California economy, representing more than 99 percent of all state businesses and providing jobs for 6.8 million, nearly half of all California’s private employees.

Yet small businesses are among the most negatively impacted by our nation’s health care system’s runaway costs and corporate insurance system. Private businesses spent $637 billion on private health insurance in 2015 and are projected to spend more than $1 trillion by 2025. Healthcare costs represent more than 17 percent of U.S. GDP, significantly higher than any country in the world.

Introduction: How Does Medicaid Expansion Affect State Budgets?

Is expanding eligibility for Medicaid a good deal for states? This question has loomed over state policymakers for more than a decade. While hundreds of studies have detailed the costs and benefits of Medicaid expansion in terms of access to care, fiscal impacts, health outcomes, and other factors, consensus remains elusive.1 Many skeptics still question whether expansion is worthwhile from a budget perspective. Fourteen states still have not expanded Medicaid, and support for expansion in states that have done so is not unanimous.

Eliminating cost-sharing and extending insurance to the uninsured will raise demand for services but the healthcare system will be able to handle this without extended wait times because reducing administrative waste will free up enough physician and nurse time to accommodate the increased demand. Critics misunderstand this because they mistakenly assume the system is efficient now, but in arguing that Medicare for All would dramatically increase utilization, they implicitly acknowledge that the current system rations access because so many Americans cannot afford to seek care.9 Indeed, wait times are not generally longer for public systems providing universal coverage.10 Where wait times are significantly longer, it is because countries choose to focus spending on what they see as higher value care. Like most countries, Canada, for example, has fewer MRI machines per capita than the US, but many more primary care doctors, allowing Canadians to see physicians almost twice as frequently as do people in the United States.11

Compared to Canada and other countries, the US has much more rationing of healthcare and longer wait times because of unaffordable costs and the lack of access to adequate insurance. More important than wait times for a few elective specialist services is the very large difference in the proportion of the sick who even try to see a doctor. Only 6% of Canadians report that in the last year they “had a medical problem but did not visit a doctor because of cost.” The proportion in the United States that did not visit a doctor because of cost is four times as large.12

In the coming decades, getting the economics of health care right will be central to the public health of the entire economy. Below, Krugman outlines the three central issues with America’s health care system and why the private health care market doesn’t work.

Potential collapse. Private health insurance markets are inherently vulnerable to collapse. In any given year, roughly 5% of people are responsible for roughly 50% of all health care costs. When a private insurer decides how much to charge for premiums, it has to figure out what its average customer is going to spend on health care that year. If the insurance company charges too low of a premium, it will not be able to cover the costs. If it charges too much, however, healthy people will decide to cancel their policies. When that happens, the percentage of insurance company’s customers who are sickly will go up and so will the average cost per patient. If that happens, the insurance company may still not take in enough in premiums to cover costs. This can create a death spiral. If the insurance company again raises their premiums to cover their increased average costs, even more patients will cancel their policies, driving average costs even higher. This process continues until only the sickest patients are willing to pay for insurance. To cover the cost, the premiums on that insurance will be at least equal to the cost of treating those patients, making it virtually unaffordable.

ABSTRACT: Biosurveillance is a relatively new term of international importance. All pandemics, mass casualties, and disease outbreaks start as a local event and present themselves to the community healthcare providers for intervention. Healthcare providers are an integral part of the solution process. On a broader scale, biosurveillance is a recently evolving disciplinary science of real-time disease outbreak detection, which can discover both natural and manmade epidemics as stated in the 2020 Handbook of Biological Warfare Preparedness by Nagaraajan et al.

As distant and unlikely as a chemical or biological event may seem to the profession of pharmacy, we should employ our pharmacy experiences gained from COVID-19 to further understand the demands of the future in a conflicted world.

In the decades to come, advanced bioweapons could threaten human existence. Although the probability of human extinction from bioweapons may be low, the expected value of reducing the risk could still be large, since such risks jeopardize the existence of all future generations. We provide an overview of biotechnological extinction risk, make some rough initial estimates for how severe the risks might be, and compare the cost-effectiveness of reducing these extinction-level risks with existing biosecurity work. We find that reducing human extinction risk can be more cost-effective than reducing smaller-scale risks, even when using conservative estimates. This suggests that the risks are not low enough to ignore and that more ought to be done to prevent the worst-case scenarios. How worthwhile is it spending resources to study and mitigate the chance of human extinction from biological risks? The risks of such a catastrophe are presumably low, so a skeptic might argue that addressing such risks would be a waste of scarce resources. In this article, we investigate this position using a cost-effectiveness approach and ultimately conclude that the expected value of reducing these risks is large, especially since such risks jeopardize the existence of all future human lives. Historically, disease events have been responsible for the greatest death tolls on humanity. The 1918 flu was responsible for more than 50 million deaths,1 while smallpox killed perhaps 10 times that many in the 20th century alone.2 The Black Death was responsible for killing over 25% of the European population,3 while other pandemics, such as the plague of Justinian, are thought to have killed 25 million in the 6th century—constituting over 10% of the world's population at the time.4 It is an open question whether a future pandemic could result in outright human extinction or the irreversible collapse of civilization. A skeptic would have many good reasons to think that existential risk from disease is unlikely. Such a disease would need to spread worldwide to remote populations, overcome rare genetic resistances, and evade detection, cures, and countermeasures. Even evolution itself may work in humanity's favor: Virulence and transmission is often a trade-off, and so evolutionary pressures could push against maximally lethal wild-type pathogens.5,6 While these arguments point to a very small risk of human extinction, they do not rule the possibility out entirely. Although rare, there are recorded instances of species going extinct due to disease—primarily in amphibians, but also in 1 mammalian species of rat on Christmas Island.7,8 There are also historical examples of large human populations being almost entirely wiped out by disease, especially when multiple diseases were simultaneously introduced into a population without immunity. The most striking examples of total population collapse include native American tribes exposed to European diseases, such as the Massachusett (86% loss of population), Quiripi-Unquachog (95% loss of population), and the Western Abenaki (which suffered a staggering 98% loss of population).9 In the modern context, no single disease currently exists that combines the worst-case levels of transmissibility, lethality, resistance to countermeasures, and global reach. But many diseases are proof of principle that each worst-case attribute can be realized independently. For example, some diseases exhibit nearly a 100% case fatality ratio in the absence of treatment, such as rabies or septicemic plague. Other diseases have a track record of spreading to virtually every human community worldwide, such as the 1918 flu,10 and seroprevalence studies indicate that other pathogens, such as chickenpox and HSV-1, can successfully reach over 95% of a population.11,12 Under optimal virulence theory, natural evolution would be an unlikely source for pathogens with the highest possible levels of transmissibility, virulence, and global reach. But advances in biotechnology might allow the creation of diseases that combine such traits. Recent controversy has already emerged over a number of scientific experiments that resulted in viruses with enhanced transmissibility, lethality, and/or the ability to overcome therapeutics.13-17 Other experiments demonstrated that mousepox could be modified to have a 100% case fatality rate and render a vaccine ineffective.18 In addition to transmissibility and lethality, studies have shown that other disease traits, such as incubation time, environmental survival, and available vectors, could be modified as well.19-21 Although these experiments had scientific merit and were not conducted with malicious intent, their implications are still worrying. This is especially true given that there is also a long historical track record of state-run bioweapon research applying cutting-edge science and technology to design agents not previously seen in nature. The Soviet bioweapons program developed agents with traits such as enhanced virulence, resistance to therapies, greater environmental resilience, increased difficulty to diagnose or treat, and which caused unexpected disease presentations and outcomes.22 Delivery capabilities have also been subject to the cutting edge of technical development, with Canadian, US, and UK bioweapon efforts playing a critical role in developing the discipline of aerobiology.23,24 While there is no evidence of state-run bioweapons programs directly attempting to develop or deploy bioweapons that would pose an existential risk, the logic of deterrence and mutually assured destruction could create such incentives in more unstable political environments or following a breakdown of the Biological Weapons Convention.25 The possibility of a war between great powers could also increase the pressure to use such weapons—during the World Wars, bioweapons were used across multiple continents, with Germany targeting animals in WWI,26 and Japan using plague to cause an epidemic in China during WWII.27 Non-state actors may also pose a risk, especially those with explicitly omnicidal aims. While rare, there are examples. The Aum Shinrikyo cult in Japan sought biological weapons for the express purpose of causing extinction.28 Environmental groups, such as the Gaia Liberation Front, have argued that “we can ensure Gaia's survival only through the extinction of the Humans as a species … we now have the specific technology for doing the job … several different [genetically engineered] viruses could be released”(quoted in ref. 29). Groups such as R.I.S.E. also sought to protect nature by destroying most of humanity with bioweapons.30 Fortunately, to date, non-state actors have lacked the capabilities needed to pose a catastrophic bioweapons threat, but this could change in future decades as biotechnology becomes more accessible and the pool of experienced users grows.31,32 What is the appropriate response to these speculative extinction threats? A balanced biosecurity portfolio might include investments that reduce a mix of proven and speculative risks, but striking this balance is still difficult given the massive uncertainties around the low-probability, high-consequence risks. In this article, we examine the traditional spectrum of biosecurity risks (ie, biocrimes, bioterrorism, and biowarfare) to categorize biothreats by likelihood and impact, expanding the historical analysis to consider even lower-probability, higher-consequence events (catastrophic risks and existential risks). In order to produce reasoned estimates of the likelihood of different categories of biothreats, we bring together relevant data and theory and produce some first-guess estimates of the likelihood of different categories of biothreat, and we use these initial estimates to compare the cost-effectiveness of reducing existential risks with more traditional biosecurity measures. We emphasize that these models are highly uncertain, and their utility lies more in enabling order-of-magnitude comparisons rather than as a precise measure of the true risk. However, even with the most conservative models, we find that reduction of low-probability, high-consequence risks can be more cost-effective, as measured by quality-adjusted life year per dollar, especially when we account for the lives of future generations. This suggests that despite the low probability of such events, society still ought to invest more in preventing the most extreme possible biosecurity catastrophes.

The intersection of public health and national security is often explored within the context of bioterrorism. SARS-CoV-2 disease 2019 (COVID-19) offers an opportunity for us to consider the national security implications of strengthening public health infrastructure and adopting a universal healthcare system. We must remember, a chain is only as strong as its weakest link. Current public health infrastructure failure and a near collapse of our costly, inefficient healthcare system, is no Black Swan. It was entirely predictable as public health professionals have been warning of such a scenario as a result of path dependency. Decisions to defund public health programs, such as the U.S. Agency for International Development (USAID)-funded global program to detect and discover viruses in animal hosts with pandemic potential, and bipartisan failure to create and sustain a federal, single-payer healthcare system that provides comprehensive coverage to everyone absent of costly insurance premiums, high deductibles and gaps in coverage, have led us to be woefully underprepared and lacking the capacity to respond to a significant global public health crisis.

The U.S. spends approximately $3.6 trillion or $11,172 per person each year on healthcare, accounting for roughly 18% of our Gross Domestic Product. The U.S. currently ranks highest in health care spending in the world. Comparatively, only $19 is spent per capita on foundational public health measures and programs, when only $32 per person is needed to meet foundational public health service needs. The U.S. spends more than $2000 per capita on its military budget. In fact, the most recent budget proposal requested more than $700 billion for national security. Both military and healthcare spending has continued to increase while public health spending has continued to decrease with an ill-informed, increasingly rare bipartisan consensus. Healthcare cost has been a known fiscal Armageddon for a while. This amount of spending is unsustainable, risks economic collapse, and puts U.S. national security at risk.

The American experience is a reminder that lack of health insurance for large parts of the population is a major barrier to mounting an effective outbreak response [5]. Taiwan has a single-payer national health insurance (NHI) scheme that covers more than 99% of the population, and emergency funding has been approved to support COVID-19 prevention efforts and affected industries [6].

Taiwan's hospitals currently have sufficient isolation rooms for confirmed and suspected cases of COVID-19. To minimise cross-infection, hospitals implemented strict triage and entrance control. To control community spread, local governments are responsible for contact tracing, quarantine enforcement and risk assessment in community settings [4].

In the United States, death rates from COVID-19 are higher than in any other high-income country—and our fragmented and inefficient health system may be largely to blame, Yale researchers say in a new study.

If the U.S. had had a single-payer universal health care system in 2020, nearly 212,000 American lives would have been saved that year, according to a new study. In addition, the country would have saved $105 billion in COVID-19 hospitalization expenses alone.

Countries like Canada, which has universal health coverage and a well-funded public health infrastructure, are much better prepared to handle deadly epidemics. In 2003, Canada confronted Severe Acute Respiratory Syndrome (SARS), which originated in China. A physician from Guangdong province inadvertently infected a number of tourists with the SARS virus, setting off a global pandemic after everyone returned to their home countries. Among the infected travelers was an elderly Canadian woman who returned to Toronto after a 10-day vacation in Hong Kong.

Over the course of about four months, the Canadian health system worked hard to contain the virus, treating 400 people who became ill and quarantining 25,000 Toronto residents who may have been exposed. Ultimately, 44 people died from the disease in Canada, but the result would have been much worse without a quick and well-organized response.

For many of us since the COVID-19 pandemic started, life may feel forever segmented into before and after the cataclysmic event that has meant nothing will ever be the same again. But scientists have long been warning of such an event. Now the statistics seem to show that not only are pandemics likely to happen, the probability of one is only going to rise.

It’s true that this was probably the first time that most of the world experienced strict lockdowns, mobility restrictions and quarantines at the same time, but in just the past few decades we have seen similar measures undertaken regionally, for instance with the SARS outbreak in 2003.

Airfinity’s new risk modelling, that is being presented at the Rhodes Summit in London Friday the 14th, indicates there’s a 27.5% chance that a pandemic as deadly as COVID-19 could take place in the next ten years. It also shows that had the original COVID-19 wild type been as transmissible as Omicron, more than 300.000 thousand people would have died in the UK alone, nearly three times more than was the case.

[Diagram]

We fear it is only a matter of time before we face a deadlier and more contagious pathogen, yet the threat of a deadly pandemic remains dangerously overlooked. Pandemics now occur with greater frequency, due to factors such as climate change, urbanization, and international travel. Other factors, such as a weak World Health Organization and potentially massive cuts to funding for U.S. scientific research and foreign aid, including funding for the United Nations, stand to deepen our vulnerability. We also face the specter of novel and mutated pathogens that could spread and kill faster than diseases we have seen before. With the advent of genome-editing technologies, bioterrorists could artificially engineer new plagues, a threat that Ashton Carter, the former U.S. secretary of defense, thinks could rival nuclear weapons in deadliness.

The feasibility of designing and dispersing biological weapons varies in difficulty depending on the biological agent in question. For instance, Bacillus anthracis, an exceptionally deadly and versatile pathogenic bacterium that causes the disease anthrax, is naturally occurring in the environment and can infect humans and animals. Anthrax has recently emerged from thawing permafrost due to the effects of climate change, and manages to persist in harsh climates and environments demonstrating its versatility.

Acquiring anthrax is relatively easy and its highly infectious spores can enter the body through inhalation of aerosols or ingestion via contaminated water supplies. Consequently, anthrax is considered one of the leading potential bioweapons. In 2001, five people in the United States died after receiving mail contaminated with anthrax — no one was caught or charged.

Recent developments in biotechnology may, however, give people the capability to design pathogens which overcome this trade-off. Some gain-of-function research has demonstrated the feasibility of altering pathogens to create strains with dangerous new features, such as vaccine-resistant smallpox 40 and human-transmissible avian flu, 41 with the potential to kill millions or even billions of people. For an engineered pathogen to derail humanity’s long-term future, it would probably have to have extremely high fatality rates or destroy reproductive capability (so that it killed or prevented reproduction by all or nearly all of its victims), be extremely infectious (so that it had global reach), and have delayed onset of symptoms (so that we would fail to notice the problem and mount a response in time).42 Making such a pathogen would be close to impossible at present. However, the cost of the technology is falling rapidly,43 and adequate expertise and modern laboratories are becoming more available. Consequently, states and perhaps even terrorist groups could eventually gain the capacity to create pathogens which could deliberately or accidentally cause an existential catastrophe.

Bill Gates, who already warned us about the pandemic and climate change, says bioterrorism is the next big threat we're not worrying about enough.

Bill Gates is widely known for his business acumen and humanitarian efforts. But the co-founder of Microsoft and multibillionaire philanthropist has also gained a reputation for predicting technological advancements as well as health crises and pandemics.

We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.

However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.

B. Health Justice as a Legislative and Policy Priority Healthcare reform in the United States should seek primarily to promote health and health justice,24 and a national single-payer program is a stepping stone toward health justice.25 But what is health justice? At its root, health justice is a state of equity in which the health system works alongside community members to envision an environment that promotes health rather than destroying it or subordinating it to non-health concerns, such as profit or social control. It is about ensuring that all people, regardless of their socioeconomic background or standing, have quality healthcare.26

Equity is not a corollary or optional consideration in healthcare. “Health protection,” the ultimate goal of any healthcare system, encapsulates “equity—timely access not linked to employment status or ability to pay” and “financial protection against catastrophic health expenditure” among other key parameters that should drive political decisions about which type of healthcare system to construct to best promote the health of a population.27

Economic justice and human rights advocates applauded Wednesday as progressives in the U.S. House and Senate reintroduced legislation to expand the Medicare system to all Americans, with the bill garnering more support in Congress than ever before.

More than half of the Democratic caucus in the House has signed on as co-sponsors of the Medicare for All Act of 2023, including 13 powerful ranking members of congressional committees.

Health insurance was supposed to improve his medical experience, but my patient couldn’t find an oncologist or hospital — even in the public system — that accepted his particular type. After months of searching, he grew discouraged; eventually he gave up. “A lot of this is on me,” he told me, ruefully.

This is the level of confusion and complexity we’ve come to accept as normal in our health care system.