Gov. Crist’s victory for unaffordable underinsurance

Quote of the Day
May 23, 2008

From the Sun-Sentinel.com:

Delivering on Gov. Charlie Crist’s top election-year priority, the Florida Legislature on (May 2, 2008) approved a health insurance package to extend no-frills coverage to the state’s 3.8 million uninsured. Crist called the health-care package “historic legislation” that will be a model for the rest of the nation.

From the Comment (Don McCanne):

Some model. It would reduce insurance premiums by stripping down benefits through measures such as limiting hospitalization and specialized services and by capping payments. Since this “doesn’t cost taxpayers a dime,” the premiums would still be unaffordable for most individuals currently without coverage. Obviously this model will not work for individuals who have health care needs.

http://www.pnhp.org/news/2008/may/gov-crists-victory-for-unaffordable-underinsurance

And…

Florida’s health plan for the uninsured has few takers

By Doug Trapp
American Medical News
February 1, 2010

Florida Gov. Charlie Crist didn’t establish a specific enrollment goal for Cover Florida, the state’s unsubsidized private insurance program for the uninsured, when he announced the start of enrollment in January 2009. But in a state with approximately 3.8 million uninsured adults, the fact that only 5,246 people signed up for one of the 27 plans in the program’s first 11 months appears to have defied all expectations.

The authorizing legislation instructed participating insurers to offer at least two types of plans: one with catastrophic and emergency department coverage, and one without.

Plan subscribers… must wait 12 months before their preexisting conditions are covered. Also, insurers balance the risk of covering such conditions by setting benefit limits as low as $25,000 each year and $50,000 in a lifetime for catastrophic plans, for example.

United HealthGroup — one of the two companies offering statewide Cover Florida plans — does not know why plan enrollment has been low, said spokesman Roger Rollman. Blue Cross and Blue Shield of Florida — the other company offering a statewide plan — directed questions to the state.

http://www.ama-assn.org/amednews/2010/02/01/gvsd0201.htm

Today’s message is not meant to be an “I told you so,” even if I did tell you. The point of the message is that health policy science has advanced to a level that the consequences of policies in various reform proposals are fully predictable. “Well, let’s try this and see how it goes” is no longer acceptable, especially for our entire $2.5 trillion health care industry.

Gov. Charlie Crist has provided us with a very valuable lesson with his “‘historic legislation’ that will be a model for the rest of the nation.” His “Cover Florida” program has left 99.9 percent of the uninsured without any coverage, while providing the other 0.1 percent with coverage that won’t work if you need health care.

This may an extreme example, but the cardinal principle is crucial. It is unsound to throw together a bunch of policies chosen based on political considerations, and then pretend that the flaws will be fixed later. You start with a core structure based on sound policies that have been proven to work.

The hybrid model before Congress, using private health insurance plans and public programs, is the most expensive model of reform, even though an important stated goal, when this process began, was to slow the increases in health care spending. The feeble measures included in the bill that allegedly would control costs do not pass basic tests of health policy science.

The hybrid model also was supposed to cover everyone, but health policy science has demonstrated that this model can’t do that. Tens of millions will be left without coverage, a number sure to increase with time.

Charlie Crist’s silly program may be an embarrassment, but that does not compare with the shame that members of Congress should be experiencing simply because they would bankrupt, maim, and kill people by walking away from sound health policy science, while they pursue what they believe will be a political victory. What a terrible, terrible shame.

Health Spending Projections Through 2019: The Recession’s Impact Continues

From the Office of the Actuary, Centers for Medicare and Medicaid Services
Health Affairs
February 4, 2010

Projections for 2010:

National Health Expenditures (NHE): $2,569.6 billion

NHE per capita: $8,289.9

NHE as percent of GDP: 17.3%

NHE projected average annual growth, 2009-2019: 6.1%

Abstract:

The economic recession and rising unemployment—plus changing demographics and baby boomers aging into Medicare—are among the factors expected to influence health spending during 2009–2019. In 2009 the health share of gross domestic product (GDP) is expected to have increased 1.1 percentage points to 17.3 percent—the largest single-year increase since 1960. Average public spending growth rates for hospital, physician and clinical services, and prescription drugs are expected to exceed private spending growth in the first four years of the projections. As a result, public spending is projected to account for more than half of all U.S. health care spending by 2012.

http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.1074v1

Woolhandler and Himmelstein: Paying For National Health Insurance — And Not Getting It (Health Affairs, July/August 2002):
http://www.pnhp.org/publications/payingnotgetting.pdf

Same story every year. Health care spending continues to increase at rates well in excess of inflation, and health care continues to represent an increasing percentage of our gross domestic product.

One important technical point. The CMS authors report that public spending will soon account for more than half of all U.S. health care spending. But they leave out two important taxpayer sources of health care financing: 1) tax subsidies in the form of tax deductions for employer-sponsored plans, and 2) the purchase of health benefit programs for public employees. In their classic paper (link above), Woolhandler and Himmelstein demonstrated that this results in a figure of government spending about fifteen percentage points higher than the numbers reported in this annual CMS report.

Using a back-of-the-envelope update, the government is already using taxpayer funds to finance about two-thirds of our national health expenditures (NHE). In a financing system that only Americans would design, a significant portion of those funds, without much transparency, are funneled through to the inefficient, wasteful private insurance plans and recategorized as private spending.

Taxpayers should be outraged. We hold the stewards of our public funds to a higher standard for responsible spending than we do for those who are shuffling funds around in a market economy.

We should be receiving much greater value for our health care spending, but we won’t under the proposal before Congress. It has been designed to funnel even more taxpayer funds to the private insurance industry, with the guarantee that they can draw off for themselves fifteen to twenty percent of the funds they receive.

With that model of a financing system, we can anticipate that we will receive the same depressing report from CMS each year until finally our finances and our health are ruined by the imposition of the forces of Stein’s Law. With a single payer national health program – an improved Medicare for all – it doesn’t have to be that way.

Increased Ambulatory Care Copayments and Hospitalizations among the Elderly

By Amal N. Trivedi, M.D., M.P.H., Husein Moloo, M.P.H., and Vincent Mor, Ph.D.
The New England Journal of Medicine
January 28, 2010

We examined the consequences of increasing copayments for ambulatory care in a large, nationally representative sample of elderly Medicare enrollees in managed-care plans. As compared with matched control plans in which copayments for ambulatory care were unchanged, Medicare plans that increased these copayments by an average of 95% for primary care and 74% for specialty care had a reduction in the number of outpatient visits but an increase in hospital admissions, in the number of days of hospital care, and in the proportion of enrollees who used hospital care. According to our estimates, for every 100 elderly enrollees exposed to this level of increased cost sharing for ambulatory care, there would be 20 fewer outpatient visits during the first year after the increase but more than 2 additional admissions for acute care and approximately 13 additional inpatient days in the year after the increase. The effects of copayment increases on the subsequent use of inpatient care were magnified for enrollees living in areas with low income and low educational levels, for black enrollees, and for enrollees who had hypertension, diabetes, or a history of acute myocardial infarction as compared with the effects observed for the entire study cohort.

http://content.nejm.org/cgi/content/full/362/4/320

Cracks in the moral hazard foundation:
http://www.pnhp.org/news/2007/september/cracks-in-the-moral-hazard-foundation

This is an important study. It demonstrates, once again, that requiring already insured patients to pay more out of pocket if they access care can have a detrimental impact on both their health and on total health care spending. This is the opposite of what we should be striving for as we attempt to reform health care. Yet Congress and the administration are including this ill-considered policy of cost sharing in the unfounded belief that it would be a harmless method of slowing health care spending.

In order to reduce premiums for private insurance plans offered by the proposed insurance exchanges, the current legislation calls for plans with actuarial values 50 to 100 percent lower than typical employer-sponsored plans (with limited exceptions). These lower values are achieved partly by requiring patients who need to use health care to pay an even larger amount out-of-pocket in the form of deductibles, copayments, and coinsurance.

Those who defend cost sharing usually cite the RAND HIE – an experiment that supposedly demonstrated that patients were not harmed by not receiving care that required out-of-pocket spending – the moral hazard argument. One problem with that study was that it was limited to the relatively healthy workforce, their young, healthy families, during a short, healthy interval in their lives. The conclusions of the study do not have external validity for an entire population, with all their ills, covered in a universal program. The study was further flawed by the fact that participants were allowed to drop out at any time and return to their prior insurance, and the cost-sharing wing did so at an eighteen-fold rate over the control wing. These individuals, many of whom were no doubt facing higher costs, were excluded from the results of the study. How can they possibly claim that the cost-sharing group fared no worse than the control group? (See the “Cracks in the moral hazard foundation” link above for further information.)

The problem of ever-increasing health care costs must be addressed, but assessing financial penalties (cost sharing) against individuals for having  accessed necessary health care is one of the very worst ways to do it. This and other studies demonstrate that it can actually increase total health care spending, not to mention impairing health outcomes.

A single payer system – an improved Medicare for all – uses much more effective policies to control health care spending while removing financial barriers to the care that patients need. Aren’t you tired of hearing the President and members of Congress tell us that single payer is the program that would work, but we’re not going to do it?

Herb Stein’s Unfamiliar Quotations

By Herbert Stein
Slate
May 16, 1997

If something cannot go on forever, it will stop.
–Stein’s Law, first pronounced in the 1980s

This proposition, arising first in a discussion of the balance-of-payments deficit, is a response to those who think that if something cannot go on forever, steps must be taken to stop it–even to stop it at once.

http://www.slate.com/id/2561/

And…

Huge Deficits May Alter U.S. Politics and Global Power

By David E. Sanger
The New York Times
February 1, 2010

… as Prof. James K. Galbraith of the University of Texas puts it, “Forecasts 10 years out have no credibility.”

Simply projecting that health care costs will rise unabated is dangerous business.

His greatest hope, Mr. Galbraith said, was Stein’s law, named for Herbert Stein, chairman of the Council of Economic Advisers under Presidents Richard M. Nixon and Gerald R. Ford.

Stein’s law has been recited in many different versions. But all have a common theme: If a trend cannot continue, it will stop.

http://www.nytimes.com/2010/02/02/us/politics/02deficit.html?hp

And…

The Long-Term Outlook for Health Care Spending

Congressional Budget Office
November 2007

Projections of Health Spending

Over the past 30 years, total national spending on health care has more than doubled as a share of GDP. Under the assumptions described (in this CBO report), according to CBO’s projections, that share will double again by 2035, to 31 percent of GDP. Thereafter, health care costs continue to account for a steadily growing share of GDP, reaching 41 percent by 2060 and 49 percent by the end of the 75-year projection period.

http://www.cbo.gov/ftpdocs/87xx/doc8758/Intro.shtml
Graph: http://www.cbo.gov/ftpdocs/87xx/doc8758/Figure4.gif

And…

GOP House Issues Conference

January 29, 2010

Congressman Paul Ryan (speaking to President Obama):  … Medicare, as you know, is a $38 trillion unfunded liability…

http://www.whitehouse.gov/the-press-office/remarks-president-gop-house-issues-conference

At over $2.5 trillion (almost 18 percent of our GDP), the level of health care spending in the United States this year is almost intolerable. Yet we hear predictions that health care will represent half of our GDP by 2082, and that Medicare will accumulate a deficit of $38 trillion.

Thank goodness for Stein’s Law. We will never see these numbers for the simple reason that this rate of increase cannot go on forever. It will stop once it hits the wall.

Herbert Stein, being from the Chicago School of Economics (think Milton Friedman), did not believe that steps must be taken to intervene since the problem would take care of itself. Although that is true, the problem with this sterile, amoral view, common amongst those of the Chicago School, is that it ignores the consequences of a spontaneous economic process devoid of the input from the heart and soul of beneficent public stewards.

To be clear, in the economics of health care, Stein’s Law does not represent one point in the expansion of health care spending at which everything stops and the health care system collapses. Nor does it represent a single point at which expansion stops and spending becomes static. Rather it represents a multitude of various walls for various payers, including individuals, employers and the various levels of government, each of which has its own wall as a barrier represented by Stein’s Law.

In our fragmented system of financing health care, Stein’s Law is already in play. Tens of millions are no longer able to afford health insurance. Tens of millions more are no longer able to afford adequate insurance products and must face the financial hardships of the underinsurance products that have been the response of competing insurers in our market economy in health care. The rate of employer-sponsored coverage has been declining because too many businesses, especially small businesses, have already hit the wall. Many states are struggling with the need to reduce Medicaid payments to providers in order to try to include more under the umbrella, while watching the safety-net of providers crumble from protracted financial losses. Even the federal government is struggling to find ways to fill the void in the face of massive budget deficits.

With Stein’s Law, we can predict that the rate of spending increases will very soon slow down, but under our current financing system, that will inevitably result in more financial hardship, suffering, and even death as health care access becomes ever less affordable.

Suppose the Senate bill passes, along with the reconciliation tweaks, then what will happen? Since our beneficent stewards in Congress neglected their duties, failing to adopt policies that would slow the growth in health care spending, health care costs will continue to test Stein’s Law.

Some of the multitude of walls will move, but none of them will go away. The states will see their walls move further out with the infusion of Medicaid funds. The federal government will see its wall move closer, signaled by the shrill cacophony of the budget hawks. Employers will not see their wall move much, but they will continue to barrel forward, eventually hitting it one by one.

But what about our hard-working, middle-income Americans? The wall will be moved much closer. For several reasons, mostly related to costs, there will be an attrition of employer-sponsored plans. Since the subsidies to purchase private plans will be less than the employer contributions, fewer individuals and families will be able to afford the plans. To slow the rise in premiums, more benefits will be stripped out. The Obama administration would accelerate this deterioration in benefits by imposing an excise tax on the plans as “the most effective way to control costs.” The Obama/Orszag policy of controlling costs by erecting financial barriers to necessary health care is a very sick policy indeed. The legislation before Congress adds afterburners to middle-income Americans only accelerating their trip to Stein’s impenetrable wall.

When our economic models have immoral consequences, we should abandon the amoral models of the Chicago School, and move to normative economics. It is not a sin for an economist to have a heart.

Under a single payer national health program – an improved and expanded Medicare for all – Stein’s wall will still be there. But instead of letting the entire system crash into the wall, our own beneficent public stewards – if we elect ones with a heart – will be there to make sure that everyone receives the care that they need. The resources that we use may take us up to the wall, but we won’t be crashing into it.

Every other industrialized nation has an impenetrable Stein wall, but by using normative economics, they don’t sacrifice their citizens by slamming them into that wall.

Remarks by the President at GOP House Issues Conference

The White House
January 29, 2010

Congressman Price (Dr. Tom Price from Georgia):  Mr. President, multiple times, from your administration, there have come statements that Republicans have no ideas and no solutions.  In spite of the fact that we’ve offered, as demonstrated today, positive solutions to all of the challenges we face, including energy and the economy and health care, specifically in the area of health care — this bill, H.R.3400, that has more co-sponsors than any health care bill in the House, is a bill that would provide health coverage for all Americans; would correct the significant insurance challenges of affordability and preexisting; would solve the lawsuit abuse issue, which isn’t addressed significantly in the other proposals that went through the House and the Senate; would write into law that medical decisions are made between patients and families and doctors; and does all of that without raising taxes by a penny.

But my specific question is, what should we tell our constituents who know that Republicans have offered positive solutions to the challenges that Americans face and yet continue to hear out of the administration that we’ve offered nothing?

The President:  It’s not enough if you say, for example, that we’ve offered a health care plan and I look up — this is just under the section that you’ve just provided me, or the book that you just provided me — summary of GOP health care reform bill:  “The GOP plan will lower health care premiums for American families and small businesses, addressing America’s number-one priority for health reform.”  I mean, that’s an idea that we all embrace.  But specifically it’s got to work.  I mean, there’s got to be a mechanism in these plans that I can go to an independent health care expert and say, is this something that will actually work, or is it boilerplate?

If I’m told, for example, that the solution to dealing with health care costs is tort reform, something that I’ve said I am willing to work with you on, but the CBO or other experts say to me, at best, this could reduce health care costs relative to where they’re growing by a couple of percentage points, or save $5 billion a year, that’s what we can score it at, and it will not bend the cost curve long term or reduce premiums significantly — then you can’t make the claim that that’s the only thing that we have to do.  If we’re going to do multi-state insurance so that people can go across state lines, I’ve got to be able to go to an independent health care expert, Republican or Democrat, who can tell me that this won’t result in cherry-picking of the healthiest going to some and the least healthy being worse off.

So I am absolutely committed to working with you on these issues, but it can’t just be political assertions that aren’t substantiated when it comes to the actual details of policy.  Because otherwise, we’re going to be selling the American people a bill of goods.  I mean, the easiest thing for me to do on the health care debate would have been to tell people that what you’re going to get is guaranteed health insurance, lower your costs, all the insurance reforms; we’re going to lower the costs of Medicare and Medicaid and it won’t cost anybody anything.  That’s great politics, it’s just not true.

So there’s got to be some test of realism in any of these proposals, mine included.  I’ve got to hold myself accountable, and guaranteed the American people will hold themselves — will hold me accountable if what I’m selling doesn’t actually deliver.

http://www.whitehouse.gov/the-press-office/remarks-president-gop-house-issues-conference

The President enters the Republicans’ den, and politics broke out. At least that’s the impression you might have from the media coverage of the President’s appearance at the GOP House Issues Conference. But this was not simply an exchange of partisan political rhetoric; it was a plea by President Obama to set aside rhetorical grandstanding and to join together in a fair, credible, and objective discussion of the impact of the actual policies under consideration.

Did that happen? It is puzzling how Congressman Tom Price, a physician, could state directly to the President that their Republican bill “would provide health coverage for all Americans.” That goes beyond political grandstanding for the benefit of the television cameras. That is shameless, arrogant lying to the President of the United States and to the American people. It is impossible to have a constructive dialogue with liars.

President Obama is right when he states that these proposals must pass the test of realism, while at the same time holding himself accountable. But realism alone isn’t enough. The policies must be effective and efficient. Yet the President and Congress abandoned those health care reform policies that pass the tests with the highest scores, and accepted flawed, lower-scoring policies that were believed to comply better with the political tests, though that political support is waning.

When objectivity and realism demonstrate that the Democratic proposal falls far short, and when better, proven policies would bring affordable care to everyone, we should hold the President and Congress accountable. But we should also support them politically when they throw the liars out so they can get on with the reform that we need.

One more lie. Congressman Price said that H.R.3400 “has more co-sponsors than any health care bill in the House.” It has 52 cosponsors. Congressman John Conyers’ H.R. 676, “United States National Health Care Act or the Expanded and Improved Medicare for All Act,” has 87 cosponsors.

More importantly, Conyers’ bill is based on sound health policy that would actually work, whereas Price’s bill is based on feeble policies that will have almost no impact on the problems we face in health care. But their bill does provide them with rhetoric they can use for political grandstanding, even if based on lies (e.g., “provides health coverage for all Americans”).

“People should go where they are not supposed to go, say what they are not supposed to say, and stay when they are told to leave.” –Howard Zinn

Well, that quote pretty well sums up “what to do”.  But my biggest challenge is “how”.  Specifically, how do I neutralize some pretty powerful fear?

I was scared Friday when I joined Margaret Flowers to attempt to deliver a message to the President.  My thoughts raced.  We’re talking secret service.

“How do I get myself into these things?”
“This is crazy.”
“This is pointless.”
“I can’t even make sensible statements; I know what I want to say but I’m so nervous.”
“Other people are so much more knowledgeable and speak so much more eloquently.”
“But I am doing it!”

We stood in front of the Harbor Hotel in Baltimore clutching a banner that read “Letting you know.  Medicare for all” and Margaret’s letter for the President written in response to his appeal for solutions to health reform.  The hotel manager, police and secret service surrounded us and asked us to move.

If you watch the video, you’ll see that there was a point, a moment, which felt suspended in time, when Margaret looked at me and I looked at her and we both knew “we ain’t goin’ across the street.”

The feeling associated with that awareness was not fear, or anger, or self-righteous indignation.  It was a feeling of quiet liberation.  The things I was saying to myself, thoughts powerful enough to imprison me in a jailhouse of fear, had been neutralized.  In their place was a calm determination to trust my intuition.

My gut told me “so be it.  You’re doing the best you can.  This is a no-brainer.  Gotta do it.  Margaret and I have been needing some quiet time to catch-up; might as well be in a police station.”

My gut has a great sense of humor.

Fear overcomes me when I listen to my head; calm enfolds me when I listen to my gut.

So, for what it is worth, here are few tips for “doing cd for Single Payer”:

1. Ignore your head.  That means, all those familiar thoughts that leave you feeling fearful and bad.

2. Listen to your gut.  You know it’s your gut talking if you start feeling calmness, clarity, and quiet determination.

3. We need people engaging in “gut-driven” cd to right all kinds of wrongs.  Be authentic; for many of us, the gut issue is Medicare For All.  If yours is the environment, then do cd for that.

4. Don’t try this alone.  Take a friend. Or several.

5. Do the best you can.  Speak from your heart.  Once you’re in handcuffs, the worst is over.  The “authorities” aren’t your enemy; most will treat you respectfully and the ones who don’t are just having a bad day.  Don’t take it personally.

6. I like to take a “token” with me, tucked in my pocket with my driver’s license. For me, it’s a picture of my grandchildren and the holy card from my father’s funeral.  It reminds me that he would be proud of me and that I’m doing this for the people who inspire me–my family and my patients.

7. If you have the choice of doing cd in the winter or the summer, definitely choose summer!  Wear layers either way because it’s cold in jail.

Remember that we all have talents to contribute.  Without Bill Hughes taking the video, our action wouldn’t have been as fruitful.  Without Kevin Zeese, we’d have worried about our families and “legal stuff.”  Without Mark Almberg, we wouldn’t have a press release.  Without researchers like David Himmelstein and Steffie Woolhandler, we wouldn’t have compelling data to support us.  We draw support from each other.

As Margaret Mead said:  Never doubt that a small group of thoughtful committed citizens can change the world. Indeed, it is the only thing that ever has.”

No Such Thing as ‘Simple’ Health Reform

By Uwe Reinhardt
The New York Times
January 29, 2010

Even before Senator-elect Scott Brown’s stunning victory in the Massachusetts special election, there was no shortage of advice on simpler approaches to health reform that the president and his Congressional allies could have used in place of the bills now before Congress.

Although the current reform bills undoubtedly are burdened with many tangential items, one can easily underestimate how quickly any kind of health reform will become complex.

(He quotes Peggy Noonan who advocates for “small, discrete steps” such as “a simple bill that mandated insurance companies offer coverage without respect to previous medical conditions.”)

In the eyes of people unfamiliar with economics, the step she (like others before her) proposes may seem small.

She seems completely unaware that, to be implemented, that step has to be accompanied by (1) a mandate to be insured or, at the least, very powerful financial incentives to be insured. And if government imposes such a mandate on citizens, it must be ready (2) to subsidize low-income families in the acquisition of the mandated insurance. Already we have a bill requiring many pages.

(He quotes from Sen. Tom Coburn’s summary of his bill calling for guaranteed coverage, and affordable premiums through risk adjustment.)

The European systems Mr. Coburn has in mind are the Swiss and Dutch health systems, because we are referred to a paper on these systems.

It should be noted that the Dutch and especially the Swiss systems are subject to heavy government regulation — far heavier than is foreseen in the Senate health reform bill passed in late December.

For example, health insurance is mandatory in both countries. Both countries prescribe purely community-rated insurance premiums which, unlike the Senate bill, cannot take the age of the insured into account. And both countries extend sizable public subsidies toward the purchase of private health insurance.

In short, as Senator Coburn’s bill illustrates, “simply” to pass a bill that imposes community rating on health insurers, as Ms. Noonan suggests, is anything but simple. It opens a veritable Pandora’s box of additional, required legislation which, once fully fleshed out, would pretty much constitute the core of the insurance-reform bill currently in the Senate bill.

http://economix.blogs.nytimes.com/2010/01/29/no-such-thing-as-simple-health-reform/

Posted response of Don McCanne, San Juan Capistrano, CA (Response #23)

Once Congress decided to build on our existing, fragmented, dysfunctional system of financing health care, it became necessary to create the complex legislation that was generated in both the House and the Senate, precisely because of the reasons Prof. Reinhardt describes.

Congress and the administration began with the most expensive system in existence and then attempted to apply social insurance principles to our hybrid model, allegedly with the goal of covering everyone with a system with sustainable spending. The health policy literature is replete with simulations and real-life studies demonstrating that this is by far the most expensive model of reform, and it falls short on universality, equity, and efficiency.

The least expensive and most effective models are a government-owned health service (socialized medicine, not America’s first choice), or a bona fide social insurance program used to finance the largely private health care delivery system. Although there is no perfect system, a government social insurance program (like Medicare) does have an advantage over social insurance programs using a market of private plans in that administrative costs are lower and mechanisms to moderate spending increases are more effective. Also, the Swiss and Dutch private insurance-based programs still leave uninsured about 1.5 percent of their populations.

President Obama this week told the nation that he was eager to see a better approach to cover everyone and bring down costs, though in his prior comments he has revealed that he already knows how to do that. And what is that?

During this break in the negotiations on reform, we really should take a serious look at an improved Medicare program that would cover everyone. It is the least expensive model of reform. It has the greatest administrative efficiency. It would truly cover everyone automatically. And even for those who do not support social solidarity, it would finally control our intolerable growth in health care spending through the proven mechanism of a single payer monopsony.

State of the Union Address

President Barack Obama
The White House
January 27, 2010

But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know.  (Applause.)  Let me know.  Let me know.  (Applause.)  I’m eager to see it.

http://www.whitehouse.gov/the-press-office/remarks-president-state-union-address

And…

Illinois AFL-CIO

Barack Obama
June 30, 2003

I happen to be a proponent of a single payer universal health care program. (applause) I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care cannot provide basic health insurance to everybody. And that’s what Jim is talking about when he says everybody in, nobody out. A single payer health care plan, a universal health care plan. And that’s what I’d like to see. But as all of you know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.

http://www.pnhp.org/news/2008/june/barack_obama_on_sing.php

Well?

Blue Shield of California to Offer Award-Winning Fitness Program to Medicare Beneficiaries in San Bernardino

Blue Shield of California
January 18, 2010

Blue Shield of California announced today that it will expand its contract with Healthways, Inc. to offer the SilverSneakers® Fitness Program to Blue Shield Medicare Advantage members in San Bernardino County. SilverSneakers, which Blue Shield already offers in Los Angeles and Orange counties, is the nation’s leading exercise program for older adults.

Using the SilverSneakers premier network, Blue Shield of California members get access to a variety of participating fitness and wellness facilities throughout the country, including such popular locations as Curves® and Bally Total Fitness®. Many sites offer amenities such as exercise equipment, treadmills and free weights, and the signature SilverSneakers fitness classes.

https://www.blueshieldca.com/bsc/newsroom/pr/sneakers_011810.jhtml

SilverSneakers: http://www.silversneakers.com/Home.aspx

Healthways SilverSneakers is a membership fitness program for seniors provided as a free benefit by many Medicare Advantage programs throughout the nation. It is not a benefit that is allowed in the traditional Medicare program.

We certainly applaud seniors who participate in programs designed to maintain physical fitness and general wellness. But there are two features of this program that should outrage taxpayers.

1) These programs are funded by government overpayments made to the private Medicare Advantage plans. Though some of the overpayments are used for additional benefits, much is wasted in excessive administrative costs and profits. Not only should taxpayers object to the waste, they should also object to a program that provides extra benefits limited to private plan enrollees but not available to those in the traditional Medicare program. If the extra benefits are appropriate, then all Medicare beneficiaries should receive them. If they are not appropriate, then no taxpayer funds should be used for these benefits. In either case, the overpayments directed to the private plans should either be redistributed amongst all Medicare beneficiaries or retained in our Medicare reserves. Regardless, the private Medicare Advantage plans should be eliminated as the wasteful intermediaries that they’ve proven to be.

2) Which of our seniors would find the SilverSneakers program to be an attractive benefit? Obviously only the healthiest without infirmities that would prevent them from participating in the exercise programs. SilverSneakers is being selectively marketed to the healthiest, lowest-cost seniors, even though their private plans are being paid much more than we spend taking care of patients in the traditional Medicare program which includes a disproportionate share of chronically ill patients. The taxpayers take care of the sick, while they doubly overpay the private plans to take care of the lower-cost healthier individuals.

The Republicans are feigning outrage by protesting that the proposal before Congress would “cut Medicare spending” by partially reducing some of the overpayments to the Medicare Advantage plans. Well, the Democrats actually are wrong. In a brave show of timidity, they suggest tweaking the Medicare Advantage overpayments, when they should show the temerity to throw those crooks out and use the funds to improve benefits in the traditional Medicare program.

While they’re at it, they should throw out the crooks running the rest of the private plans, and establish an improved Medicare program for all of us.

What about the seniors who would lose their SilverSneakers membership? They can buy a program directly from Curves or Bally Total Fitness, thereby eliminating both the SilverSneakers and the Medicare Advantage middlemen. Or better yet, they can organize their own fitness groups and continue to exercise – for free!

Liability Limits in Texas Fail to Curb Medical Costs

by David Arkush, Peter Gosselar, Christine Hines and Taylor Lincoln
Public Citizen
December 2009

Supporters of limiting health providers’ liability have touted Texas’ medical malpractice experiment as the solution for improving national health care. For example, Minnesota Rep. Michele Bachmann held up Texas as a successful liability “pilot program” in an address in September, stating, “The state of Texas did a wonderful job of lawsuit reform and actually saw medical costs come down. We know it works.”

But most of the claims touting positive effects of the Texas law – which took effect in September 2003 and included a $250,000 per defendant liability cap – are flatly contradicted by the data.

By the measures commonly used to evaluate health care – such as cost, the uninsured rate, and access to care – Texas has regressed since its liability law took effect. Collectively, these measures show that Texas has one of the worst health care systems in the United States. Moreover, since 2003 Texas has either failed to improve or grown even worse compared to other states on almost every measure.

Since the liability laws took effect:

* The cost of health care in Texas (measured by per patient Medicare reimbursements) has increased at nearly double the national average;
* spending increases for diagnostic testing (measured by per patient Medicare reimbursements) have far exceeded the national average;
* the state’s uninsured rate has increased, remaining the highest in the country;
* the cost of health insurance in the state has more than doubled;
* growth in the number of doctors per capita has slowed; and
* the number of doctors per capita in underserved rural areas has declined.

http://www.citizen.org/documents/Texas_Liability_Limits.pdf

The malpractice system does not serve injured patients well. It needs to be reformed. It needs to be redesigned with incentives to reduce exposure to error, and to appropriately compensate patients when error does occur, all in a non-hostile environment that serves the interests of both patients (compensation for injury) and health care professionals (performance enhancement). This is not the topic of today’s message.

The Republican grandstanding has been sending a message calling for a blanket rejection of any reform advanced by the Democrats, and instead substituting the opening of insurance markets across state borders and the enactment of malpractice reform.

Since expanding insurance markets across state borders is not the topic of today’s message, we’ll quickly dismiss it as an unsound policy that would flood the market with less expensive underinsurance products that would fail to provide financial security for those who need health care. That is the worst possible way to expand health care coverage.

Regarding malpractice, when Republicans and some Democrats (except those beholden to trial attorneys) call for reducing health care spending through malpractice reform, they don’t really mean reform. They are merely calling for a cap on general damages (pain and suffering), such as the $250,000 cap enacted in Texas. They contend that this would reduce costs by eliminating excessive awards for “junk lawsuits,” and especially by reducing the pressure on physicians to order unnecessary tests. Many contend that the excess CYA testing is a major cause of our very high health care spending.

So what has happened in Texas after the cap was applied? Health care costs have increased at double the national average! Spending increases for diagnostic testing have far exceeded the national average! The cost of health insurance has more than doubled!

As an isolated policy, malpractice caps were ineffective in reducing spending and diagnostic testing in Texas. The issue of general damages needs to be addressed as part of a process leading to comprehensive malpractice reform, but it should be dismissed as the be all and end all for comprehensive health system reform.

The debate over malpractice should not distract us from our mission to support comprehensive reform that would ensure that absolutely everyone receives the health care that they need, under a financing system that eliminates the burden of medical debt. (Hint: a single payer national health program – an improved Medicare for all)