Wednesday, May 10, 2023

Ronald Steel, Critic of American Cold War Policies, Dies at 92



Ronald Steel, Critic of American Cold War Policies, Dies at 92

In essays and books. he saw the U.S. postwar era as a series of misadventures spawning unwise wars. He also wrote the definitive biography of the journalist Walter Lippmann.

Ronald Steel, a historian who derided America’s Cold War foreign policies as a succession of misguided adventures and wrote a definitive biography of Walter Lippmann, the dean of 20th-century foreign policy realism, died on Sunday in Washington. He was 92.

The death, at a nursing home, was caused by complications of dementia, said his longtime physician and friend, Michael Newman.

A bookish, small-town boy from Illinois who became a soldier, wanderer, translator, diplomat, journalist, author and professor, Mr. Steel since the early 1960s had been one of the nation’s most prolific critics of America’s master plans for navigating a perilous, changing world. He often examined his subjects through prisms of biography and magazine profiles of those who shaped foreign policies.

In the high-stakes game of global chess, Mr. Steel infuriated presidents, secretaries of state and other national leaders with astringent yet sparkling essays that filled seven books and hundreds of commentaries in The New Republic, The New York Times and The New York Review of Books. He also taught at Yale, Princeton, the University of Southern California and other colleges.

His best-known book, “Walter Lippmann and the American Century” (1980), was the story of the most influential journalist of his age, who founded The New Republic, was a confidant of presidents from Woodrow Wilson to Lyndon Johnson and reached millions with syndicated columns that argued for a foreign policy of pragmatism rather than a global crusade against Communism.

One of the most discussed political biographies of its time and a best seller, the Lippmann biography won the National Book Critics Circle Award for general nonfiction, Columbia University’s Bancroft Prize and The Los Angeles Times Book Prize for History, and was a finalist for the National Book Award and the 1981 Pulitzer Prize for biography. Its critical reception was divided, largely along political lines.

Basically, Mr. Steel insisted that Washington’s strategy for dealing with Moscow — the postwar “containment doctrine” that defined American policy toward the Soviet Union for four decades — had been wasteful and deluded, spawning costly wars in Korea and Vietnam and obsessions with national security that left Americans no more secure, prosperous or free than the rest of the world.

The American diplomat in Moscow George F. Kennan articulated that doctrine in the journal Foreign Affairs in 1947, proposing “a policy of firm containment, designed to confront the Russians with unalterable counterforce at every point where they show signs of encroaching upon the interests of a peaceful and stable world.” President Harry S. Truman made it official as “the Truman Doctrine.”

“The watershed event of the Truman presidency was certainly the Korean War,” Mr. Steel wrote in a retrospective commentary in The New Republic in 1992. “It transformed the vague rhetoric of the Truman Doctrine into a blueprint for interventions against communism that set the precedent in Vietnam and the proxy wars of the Reagan era.”

In his first book, “The End of the Alliance” (1964), Mr. Steel argued that the North Atlantic Treaty Organization was already obsolete five years after its birth in 1949 and that it should be dissolved as a way of stepping back from what he regarded as the growing prospect of a nuclear war between the United States and the Soviet Union.

In “Pax Americana” (1967), he warned of an obsession with “the Communist menace.” The title came from a 1963 speech by President John F. Kennedy urging Americans to reflect on their Cold War attitudes, asking: “What kind of peace do we seek? Not a Pax Americana enforced on the world by American weapons of war.” The historian Henry Steele Commager called the book “the most persuasive critique of American foreign policy over the last 20 years.”

As many Americans debated and eventually soured on the Vietnam War, some scholars began to question whether the United States had become a counterrevolutionary power committed to the defense of a global status quo. Mr. Steel extrapolated on that point in his review, in The New York Times, of Neil Sheehan’s book “A Bright Shining Lie: John Paul Vann and America in Vietnam” (198
“Vietnam is the graveyard of an image we held of ourselves: America as the defender of the oppressed,” Mr. Steel wrote. “In Vietnam we were confronted with ourselves as an imperial power, fighting not for democracy but to demonstrate that Communist-led ‘wars of national liberation’ were not the wave of the future.”

Even after the Soviet Union collapsed in 1991, Mr. Steel contended, in “Temptations of a Superpower” (1995), that American foreign policy remained incoherent because, he wrote, it was based on activism by presidents promoting their own political interests and causes, and because America still viewed itself as a global policeman, determined to guarantee stability around the world.

Lauding the book, Alan Tonelson, a fellow of the Economic Policy Institute at the time, wrote in The New York Times Book Review: “In a political climate where the labeling of all dissenting foreign policy voices as ‘isolationist’ is praised in the news media as responsible leadership, Mr. Steel’s essay is a rare example of clarity, wisdom and intellectual integrity.”

Mr. Steel, in “New Perspectives Quarterly” in 1997, sounded yet another warning.

“The disappearance of the rival superpower, which was also the ideological challenger, has not resulted in any contraction of American global goals,” he wrote. “The ‘free world’ has now been extended to virtually the entire world as anti-communism, in American geopolitical strategy, has been replaced by the amorphous concept of global order.”

Ronald Lewis Sklut was born on March 25, 1931, in Morris, Ill., the older of two sons of Abe and Beatrice (Mink) Sklut. His father, a Jewish immigrant from Russia, owned a clothing store. Ronald and his brother, Bruce, attended public schools in Morris, 30 miles southwest of Chicago.

“I did a lot of reading, but mostly in secret so that I wouldn’t be considered bookish by the regular guys,” Mr. Steel wrote in an autobiographical sketch for the reference book World Authors after adopting the nom de plume Ronald Steel in about 1960. “I was also aware, as one of the few Jews in a very small farm town, that this was considered an extremely odd and exotic thing to be.”

He graduated from Northwestern University in 1953 with a Bachelor of Arts degree in political science and English and earned a master’s degree in political economy from Harvard in 1955. Fluent in French when drafted by the Army, he was posted to a general’s staff in Paris. After his discharge, he joined the Foreign Service and was a vice consul in Hamburg in 1957-58. Returning to New York, he became the editor of Scholastic Magazines from 1959 to 1962.

Later in the 1960s he lived in Paris and London, translated French books on European politics and business affairs, and wrote his first two books. He also wrote articles on American foreign policy for The New York Review of Books, many of them collected in an ironically titled volume, “Imperialists and Other Heroes: A Chronicle of the American Empire” (1971).

Mr. Steel began working on his biography of Mr. Lippmann in the early 1970s. It took nearly a decade, a task complicated, he said, by Mr. Lippmann’s reluctance to reveal “personal” aspects of his life.

Anthony Lewis, in The Times, called the Lippmann book “candid and balanced,” adding, “Steel does not flinch from unpleasant facts or critical judgments.”

But Joseph Epstein, the former editor of The American Scholar, called it “a catalog of revisionist presuppositions, assumptions and notions” and “scarcely more than a checklist of Walter Lippmann’s opinions.”

In “Partial Payments: Essays on Writers and Their Lives” (1989), Mr. Epstein took Mr. Steel to task as a writer and historian. “In foreign policy, Steel’s point of view is that of a revisionist, which means he believes that the past 40 years or so in American foreign policy have been a period of imperialist intention,” with the United States seeking “world hegemony.”

He added: “Steel views the Cold War as more the fault of the United States than of the Soviet Union, and in his own journalism he has shown a great impatience with what he construes to be the screen of moral babble, paranoia and simple hypocrisy behind which American policy has operated.”

Mr. Steel’s last book, “In Love With Night: The American Romance with Robert Kennedy” (2000), attacked what he called myths about the senator that arose after his assassination in Los Angeles during the 1968 presidential primaries — that “had he lived and become president, he would have quickly ended the war in Vietnam, brought Black and white Americans together, alleviated poverty and discrimination, and achieved a more just and humane society.” Mr. Steel said “there is little, beyond hope and need, to lead us to believe” that R.F.K. would have achieved such goals.

Starting in the early 1970s, Mr. Steel taught at Yale, the University of Texas, Wellesley College, Rutgers University, U.C.L.A., Dartmouth, George Washington University, the Woodrow Wilson International Center for Scholars in Washington, the University of Paris, the American Academy in Berlin and Princeton. He taught at U.S.C. from 1986 until he retired in 2008.

He is survived by his brother, Bruce Sklut. Mr. Steel’s cognitive impairment progressed in 2016, and since then he had lived at the Sunrise nursing home Sunrise on Connecticut Avenue in Washi


He had kept an apartment in Washington for years, and rarely visited his hometown in Illinois.

“I lived in New York and Paris and London, and in a dozen other places across the globe that for a time I called home,” Mr. Steel told World Authors. “All those places shaped me in one way or another. But somewhere along the way I also stopped trying to escape from the small town. Confinement, I’ve come to think, lies more in the head than in the place.”




Monday, May 08, 2023

Corporate Giants Buy Up Primary Care Practices at Rapid Pace - NYT


Corporate Giants Buy Up Primary Care Practices at Rapid Pace

Large health insurers and other companies are especially keen on doctors’ groups that care for patients in private Medicare plans.

It’s no surprise that the shortage of primary care doctors — who are critically important to the health of Americans — is getting worse.

They practice in one of medicine’s lowest paid, least glamorous fields. Most are overworked, seeing as many as 30 people a day; figuring out when a sore throat is a strep infection, or managing a patient’s chronic diabetes.

So why are multibillion-dollar corporations, particularly giant health insurers, gobbling up primary care practices? CVS Health, with its sprawling pharmacy business and ownership of the major insurer Aetna, paid roughly $11 billion to buy Oak Street Health, a fast-growing chain of primary care centers that employs doctors in 21 states. And Amazon’s bold purchase of One Medical, another large doctors’ group, for nearly $4 billion, is another such move.

The appeal is simple: Despite their lowly status, primary care doctors oversee vast numbers of patients, who bring business and profits to a hospital system, a health insurer or a pharmacy outfit eyeing expansion.

And there’s an added lure: The growing privatization of Medicare, the federal health insurance program for older Americans, means that more than half its 60 million beneficiaries have signed up for policies with private insurers under the Medicare Advantage program. The federal government is now paying those insurers $400 billion a year.

“That’s the big pot of money everyone is aiming at,” said Erin C. Fuse Brown, director of the Center for Law, Health & Society at Georgia State University, and an author of a New England Journal of Medicine article about corporate investment in primary care. “It’s a one-stop shop for all your health care dollars,” she said.

Many doctors say they are becoming mere employees. “We’ve seen this loss of autonomy,” said Dr. Dan Moore, who recently decided to start his own practice in Henrico, Va., to have more say in caring for his patients. “You don’t become a physician to spend an average of seven minutes with a patient,” he said.

The absorption of doctor practices is part of a vast, accelerating consolidation of medical care, leaving patients in the hands of a shrinking number of giant companies or hospital groups. Many already were the patients’ insurers and controlled the distribution of medicines through ownership of drugstore chains or pharmacy benefit managers. But now, nearly seven of 10 of all doctors are either employed by a hospital or a corporation, according to a recent analysis from the Physicians Advocacy Institute.

The companies say these new arrangements will bring better, more coordinated care for patients, but some experts warn the consolidation will lead to higher prices and systems driven by the quest for profits, not patients’ welfare.

Insurers say their purchase of medical practices is a step toward what is called value-based care, with the insurer and doctor paid a flat fee to care for an individual patient. The fixed payment acts as a financial incentive to keep patients healthy, provide more access to early care and reduce hospital admissions and expensive visits to specialists.

The companies say they favor the fixed fees over the existing system that pays doctors and hospitals for every test and treatment, encouraging doctors to order too many procedures.

Under Medicare Advantage, doctors often share profits with insurers if the doctors take on the financial risk of a patient’s care, earning more if they can save on treatment. Instead of receiving a few hundred dollars for an office visit, primary care doctors can be paid as much as $14,000 a year to manage a single patient.

But experts warn these major acquisitions threaten the personal nature of the doctor-patient relationship, especially if the parent company has the authority to dictate limits on services from the first office visit to extended hospital stays. Once enrolled, these new customers can be steered toward chains of related businesses, like a CVS drugstore or Amazon’s online pharmacy.

UnitedHealth Group is a sprawling example of consolidated services. It owns the major insurer that has nearly 50 million customers in the United States and oversees its ever-expanding subsidiary, Optum, which has bought up networks of doctors and medical sites. Optum can send patients from one of its roughly 70,000 doctors to one of its urgent care or surgery centers.

Senator Elizabeth Warren, Democrat of Massachusetts, is urging the Federal Trade Commission to take a closer look at some of these large deals, which regulators have so far not blocked on antitrust grounds. “I fear that the acquisition of thousands of independent providers by a few massive health care mega-conglomerates could reduce competition on a local or national basis, hurting patients and increasing health care costs,” she wrote to regulators in March.

This consolidation of medical care may also run afoul of state laws that prohibit what is called corporate medicine. Such statutes prevent a company that employs doctors from interfering with patient treatment.

And experts warn of the potential harm to patients, when corporate management seeks to control costs through byzantine systems requiring prior authorization to receive care.

For example, Kaiser Permanente, the giant nonprofit health plan that also owns physician groups, settled a malpractice case for nearly $2.9 million last year with the family of Ken Flach, a former tennis player who contracted pneumonia and died from sepsis after a Kaiser nurse and doctor would not send him for an in-person visit or to the emergency room, despite the urgent pleading of his wife. Kaiser said medical decisions are made by its providers in consultation with their patients and said its “deepest sympathy remains with the Flach family.”

Doctors also chafe at oversight that does not benefit patients. “They are trying to run it like a business, but it’s not a business,” said Dr. Beth Kozak, an internal medicine doctor in Grand Rapids, Mich.

Her doctors’ group has teamed up with Agilon Health, an investor-owned company, to work with Medicare Advantage plans. Dr. Kozak said she has to work longer hours, not to provide better care, but to supply additional diagnoses for patients, which increases federal reimbursements under the Medicare Advantage program. “It’s not because I’m giving better patient care,” she said. “It’s all tied to the billing.”

The corporate consumption of medical care keeps growing. Walgreens Boots Alliance, one of the largest U.S. pharmacy operations, spent $5 billion for a majority stake in VillageMD, a primary care group, and teamed with Cigna to buy another medical group for nearly $9 billion. And short of an outright purchase, UnitedHealth is partnering with Walmart to offer care to older patients.

In promoting the benefits of buying Oak Street clinics to investors, Karen S. Lynch, the chief executive of CVS Health, said primary care doctors lower medical costs. “Primary care drives patient engagement and positive clinical outcomes,” she said.

Many of these companies are building chains of clinics. On a recent tour of an Oak Street clinic in Bushwick, one of 16 centers opened since October 2020 in New York City, patients were typically seen from 8 a.m. to 5 p.m., with a nurse available after hours to field questions.

Ann Greiner, the chief executive of the Primary Care Collaborative, a nonprofit group, defended the recent forays by private companies into this field of health care, saying they are infusing practices with sorely needed funds and may improve access to care for people in underserved areas.

“The salaries of the folks in those arrangements are higher,” she said. “They are providing more comprehensive care in many of those arrangements. They are providing more tech and more team-based care. That’s all investment.”

But these deals also risk shifting the balance from quality treatment to profits, she said.

In recent years, some have invoked the laws banning corporate medicine to challenge these large-scale private operations. Envision Healthcare, a private equity-backed company that employs emergency room doctors, is being sued in California by a unit of the American Academy of Emergency Medicine, a professional group that supports independent practices, accusing it of violating that state’s provisions.

“Envision exercises profound and pervasive direct and indirect control and/or influence over physicians practice of medicine,” according to the lawsuit. The suit maintains that Envision controls the doctors’ billing and establishes medical protocols.

While Envision would not comment on the litigation, it said it “follows an operating structure that is common across the health care sector and widely used by nonprofit, privately held and public groups as well as hospitals and insurers.”

The big insurers find doctors’ groups particularly attractive, although many have reported sizable losses. The acquisition of Oak Street, which has lost more than $1 billion over the last three years, could help CVS’s Medicare Advantage plans improve their quality or “star” ratings and increase payments for one of its plans.

Even small numbers of patients can translate into significant revenue. One Medical, the company Amazon owns, is best known for sleek clinics. The company scooped up a practice specializing in Medicare Advantage. Only about 5 percent of One Medical’s 836,000 members are enrolled in that federal program, but roughly half of its revenue comes from that tiny slice of patients, according to its 2022 financial statements.

Regulators are already flagging questionable methods employed by some practices. In November 2021, Oak Street disclosed that the Justice Department was investigating sales ploys like free trips to its clinics and payment of insurance agents for referrals. One doctor at a center described recruiting patients with “gift cards, swag and goody bags,” according to a shareholder lawsuit against Oak Street.

The lawsuit detailed concerns that doctors were inflating the payments from the federal government by overstating how sick their patients were.

Oak Street says it has not been accused of any wrongdoing by the Justice Department and says the lawsuit is “without merit.”

These private Medicare Advantage plans have been heavily criticized for racking up enormous profits by inflating costs and exaggerating patients’ illnesses to charge the government more than they should.

Under new rules, the Biden administration would eliminate some of the most problematic, overused diagnoses, and doctors and insurers could earn less.