Property rights are America's state religion, and so market-oriented language is the holy catechism. But the things we value most highly aren't property, they cannot be bought or sold in markets, and describing them as property grossly devalues them. Think of human beings: murder isn't "theft of life" and kidnapping isn't "theft of children":

theguardian.com/technology/200…

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"Intellectual property" is a silly euphemism

Owning a song or a piece of writing isn't like owning a television, and to call it anyone's 'property' is seriously misleading

^{Cory Doctorow (The Guardian)}

When we use markets and property relations to organize these non-market matters, horrors abound. Just look at the private equity takeover of American health-care. PE bosses have spent more than a *trillion* dollars cornering regional markets on various parts of the health system:

pluralistic.net/2024/02/28/500…

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The PE playbook is plunder. After PE buys a business, it borrows heavily against it (with the loan going straight into the PE investors' pockets), and then, to service that debt, the new owners cut, and cut, and cut. PE-owned hospitals are literally filled with *bats* because the owners stiff the exterminators:

prospect.org/health/2024-02-27…

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Scenes From the Bat Cave

How Steward Health left a Space Coast community hospital in a literal world of shit

^{Maureen Tkacik (The American Prospect)}

Needless to say, a hospital that is full of bats has other problems. All of the high-tech medical devices are broken and no one will fix them because the PE bosses have stiffed all the repair companies and contractors. There are blood shortages, saline shortages, PPE shortages. Doctors and nurses go weeks or months without pay. The elevators don't work. Black mold climbs the walls.

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When PE rolls up all the dialysis clinics in your neighborhood, the new owners fire all the skilled staff and hire untrained replacements. They dispense with expensive fripperies like sterilizing their needles:

thebignewsletter.com/p/the-dir…

When PE rolls up your regional nursing homes, they turn into slaughterhouses. To date, PE-owned nursing homes have stolen at least 160,000 lost life years:

pluralistic.net/2021/02/23/acc…

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The Dirty Business of Clean Blood

We have given the power of life or death over more than half a million people to two dialysis monopolies, DaVita and Fresenius. A non-compete ban could change that.

^{Matt Stoller (BIG by Matt Stoller)}

Then there's hospices, the last medical care you will ever receive. Once your doctor declares that you have less than six months or less to live, Medicare will pay a hospice $243-$1,462/day to take care of you as you die. At the top end of that rate, hospices have to satisfy a lot of conditions, but if the hospice is willing to take $243/day, they effectively have *no* duties to you.

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They don't even have to continue providing you with your regular medication or painkillers for your final days:

prospect.org/health/2023-04-26…

Setting up a hospice is cheap as hell. Pay a $3,000 filing fee, fill in some paperwork (which no one ever checks) and hang out a shingle. Nominally, a doctor has to oversee the operation, but PE-backed hospices save money here by having a single doctor "oversee" *dozens* of hospices:

auditor.ca.gov/reports/2021-12…

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Born to Die

Medicare spends tens of billions of dollars on hospice care each year. A new report ponders why regulators insist on going easy on literal death merchants.

^{Maureen Tkacik (The American Prospect)}

Once you rope a patient into this system, you can keep billing the government for them up to a total of $32,000, then you have to kick them out. Why would a patient with only six months to live survive to be kicked out? Because PE companies pay bounties to doctors to refer patients who *aren't* dying to hospices. 51% of patients in the PE-cornered hospices of Van Nuys are "live discharged":

pluralistic.net/2023/04/26/dea…

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However, once you're admitted to a hospice, Medicare expects you to die - so "live discharged" patients face a thick bureaucratic process to get back into the system so they can start seeing a doctor again.

So all of this is obviously very bad, a stark example of what happens when you mix the most rapacious form of capitalist plunder with the most vulnerable kind of patient.

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But, as Elle Rothermich writes for LPE Journal, the PE model of hospice is merely a more extreme and visible version of the ghastly outcomes that arise out of *all* for-profit hospice care:

lpeproject.org/blog/hospice-co…

The problems of PE-owned hospices are not merely a problem of the lack of competition, and applying antitrust to PE rollups of hospices won't stop the carnage, though it would certainly improve things somewhat.

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Hospice Commodification and the Limits of Antitrust

As hospice care is increasingly dominated by private equity firms, an antitrust response, while necessary, has the potential to normalize the language of the market as the default mode for discussing…

^{LPE Project}

While once American hospices were run by nonprofits and charities, that changed in 1983 with the introduction of Medicare's hospice benefit. Today, three quarters of US hospices are private.

It's not just PE-backed hospices; the entire for-profit hospice sector is worse than the nonprofit alternative. For-profit hospices deliver worse care and worse outcomes at higher prices. They are the worst-performing hospices in the country.

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This is because (as Rothermich writes) "The actual provision of care—the act of healing or attempting to heal—is broadly understood to be something more than a purely economic transaction." In other words, patients are not customers. In the hierarchy of institutional obligations, "patients" rank *higher* than customers. To be transformed from a "patient" into a "customer" is to be severely demoted.

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Hospice care is a complex, multidisciplinary, highly individualized practice, and pain treatment spans many dimensions: "psychological, social, emotional, and spiritual as well as physical." A cash-for-service model inevitably flattens this into "a standardized list of discrete services that can each be given a monetary value: pain medication, durable medical equipment, skilled nursing visits, access to a chaplain."

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As Rothermich writes, while there are benefits to blocking PE rollups and monopolization of hospices, to do so at all tacitly concedes that health care should be treated as a business, that "corporate involvement in care delivery is an inevitable, irreversible development."

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Rothermich's point is that health care isn't a commodity, and to treat it as such always worsens care. It dooms patients to choosing between different kinds of horrors, and subjects health care worker to the moral injury of failing their duty to their patients in order to serve them as customers.

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I'm on a tour with my new book, the international bestseller *Enshittification*!

Catch me next in #Cardiff (TONIGHT!), #Oxford and #London!

Full schedule with dates and links at:

pluralistic.net/tour

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