Orszag: Defined Contributions Define Health-Care Future

By Peter Orszag
Bloomberg, December 6, 2011

Over the next decade, we are likely to see a shift in health insurance in the U.S.: So-called defined-contribution plans will gradually take over the market, shifting the residual risk of incurring high health-care costs from employers to workers.

The market today is dominated by “defined-benefit” plans, under which companies determine a set of health-insurance benefits that are provided for employees. These will gradually be replaced by defined-contribution plans, under which companies pay a fixed amount, and employees use the money to buy or help pay for insurance they choose themselves.

The fundamental driver of this shift is the effort by American businesses to reduce their exposure to health-care costs. But the recent health-care-reform law may accelerate the shift.

The change in health insurance is already well under way in coverage for retirees. In the early 1990s, in response to accounting changes and rising costs, companies began to re- evaluate retiree health plans, and some capped the amount they were willing to pay at a multiple of existing costs. Over time, as those limits were reached, most companies declined to raise them, thereby effectively creating defined-contribution retiree health-insurance plans, with the company’s contribution set by the cap. Exchanges have been created to allow retirees to use these employer contributions to purchase their own health insurance.

For current workers, the precursor to a defined- contribution approach is the “consumer-driven” health plan. This typically has higher deductibles and co-payments than a traditional plan has, and it is often tied to a health savings account. It typically still provides generous insurance for catastrophic cases.

Some insurers are already anticipating the shift. Bloom Health Corp. will begin offering defined-contribution exchanges in 2012. Bloom, based in Minneapolis describes itself as “a leader in the defined-contribution health benefits marketplace,” and says it is “committed to assisting employers of all sizes move toward an employer-sponsored system that has effective cost predictability for employers and increased choice and personalization for employees.” In September, the company announced that Health Care Service Corp., Blue Cross Blue Shield of Michigan and WellPoint (WLP) Inc. had purchased a majority of its equity.

The inevitable transition to defined-contribution health insurance may get a little push from the new health-care-reform law. Indeed, the legislation may have a larger impact on the type of health-insurance plan that employers offer than on their decision about whether to drop health-care benefits altogether.

If most employers do retain their health plans, the state insurance exchanges created under the new federal health-care law will make the basic idea of a defined-contribution health plan more prevalent, and thus may speed its adoption. The regulations written to carry out the new law will determine how things play out. If defined-contribution plans that are sufficiently generous count as employer-based coverage – as is generally expected – the trend toward such plans will probably accelerate.

In any case, the bottom line is that a shift toward defined-contribution plans seems likely. I’d be willing to bet $1 that most large U.S. employer health-care offerings in 2020 will be defined-contribution plans. Any takers?

(Peter Orszag is vice chairman of global banking at Citigroup Inc. and a former director of the Office of Management and Budget in the Obama administration. The opinions expressed are his own.)

http://www.bloomberg.com/news/2011-12-07/defined-contributions-define-health-care-ahead-commentary-by-peter-orszag.html

One of the more important tools to enable the transfer wealth up the income ladder is to shift from defined benefit programs to defined contributions. With a defined contribution, a set dollar amount is contributed to the program regardless of what the future benefits may cost, whereas with a defined benefit program, the projected costs of the program must be fully funded so the benefits will always be there when needed.

In the case of pension plans, a defined contribution allows the employer to shift the risk of wage inflation and the risk of living longer from the employer to the employee. The latter is particularly a problem since many individuals will outlive the funds accumulated in their defined contribution pension plan. It is true that they could use those funds to buy an annuity, but fewer funds would be available because it is not a defined benefit plan, and converting to an annuity burns up even more of the retirement funds to pay for sales and administrative costs plus the costs of insuring against the risk of living longer.

How does this move wealth up the income ladder? Defined benefit pension plans were considered to be a standard part of the well-earned employee benefit package. These defined benefit plans were actually paid for by foregone wage increases. In the last couple of decades, contributions to the pension plans were limited by changing to defined contribution, yet wages remained flat. The foregone wages never came back. Workers suffered a net loss, while employer/owners kept the difference, thus an upward transfer of wealth.

Now we are seeing this same inequitable concept being applied to employer-sponsored health plans. Traditional health plans provided generous benefits and often had an actuarial value of 90 percent (the plan paid 90 percent of health care costs and the worker paid 10 percent). We are now seeing a decline in actuarial value. The most obvious contributing factor is the relatively abrupt increase in the adoption of high-deductibles for employer-sponsored plans, but also benefits covered are diminishing, often through less transparent, innovative changes to the plans. Once again, benefits are being reduced but without a commensurate return of forgone wages.

Particularly alarming in Peter Orszag’s article is the investment of WellPoint and Blue Cross Blue Shield of Michigan in Bloom Health Corporation. Bloom Health is “a leader in the defined-contribution health benefits marketplace.” They are committed to a system that has “effective cost predictability for employers,” but exposes employees to the ever higher costs and risks of health care.

This ongoing shift to defined contribution in health care is not limited to businesses. In a recent message, we reported that the Institute of Medicine is recommending that the essential health benefits for the state insurance exchanges under the Affordable Care Act “should be defined as a package that will fall under a predefined cost target rather than building a package and then finding out what it would cost.” “Predefined cost target” is a defined contribution.

Even Medicare is vulnerable. The New York Times, in a recent editorial, stated that for Medicare, “serious analysis and testing of premium support are clearly worth pursuing.” Premium support is a defined contribution that would be used to purchase a private Medicare plan. Medicare beneficiaries would be responsible for paying for the balance of the premium for whatever coverage they could get. Further, with tight control of the defined contribution, an increasing percentage of health care costs would be shifted to Medicare patients in the form of higher out-of-pocket spending.

What do all of these have in common? They are all methods of perpetuating the private insurance industry, while shifting risks from the insurers to the insured individuals. They reduce the financial commitment of employers and the government, but increase the financial burden for workers, their families, and retirees – most of us. However, it is a jobs program – for personal bankruptcy attorneys, as if our health care system didn’t give them enough work already.

Defined contribution is a nefarious conspiracy directed at the masses to benefit the well off. We can counter by demanding an end to a system dominated by private insurers and replacing it with a single, publicly-financed and publicly-administered national health program – an improved Medicare for everyone.

(After we fix Medicare, we may want to think about greatly reinforcing our publicly-financed, publicly-administered, defined benefit Social Security program so we wouldn’t have to put up with the abuses of our private, defined contribution pension plans. Really.)

Medicare Advantage Premiums To Fall 4% Next Year

By Phil Galewitz
Kaiser Health News, September 15, 2011

The Obama administration on Thursday said the nearly 12 million senior citizens enrolled in Medicare health plans will see their monthly premiums drop by an average of 4 percent while benefits remain stable next year.

Enrollment in the plans, which now have about a quarter of all Medicare beneficiaries, is expected to grow by 10 percent in 2012, said Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services.

He attributed the premium drop to the agency’s strong negotiations with plans as well as the companies’ continuing desire to serve the market.

Dan Mendelson, the chief executive of consulting firm Avalere Health, said plans are lowering premiums because their costs have fallen as their members have used fewer services in the midst of the economic downturn.

The plans were targeted by Democrats who complained that the government pays more per capita for beneficiaries in the private plans than it spends on those in traditional Medicare.

Federal payments were frozen to Medicare Advantage plans this year and are dropping by less than 1 percent in 2012.

The health care law softens the impact of Medicare Advantage cuts in 2012 by providing billions of dollars for quality bonuses for highly rated plans that received four or five stars in a government grading system.

In a policy shift last fall, HHS decided to lower the bar for bonuses. Average-quality plans garnering just three or three-and-a-half stars would also get bonuses, although at a lower percentage than top-tier plans.

The HHS decision means that nearly 90 percent of Medicare Advantage enrollees are in plans now eligible for a bonus. Under the tougher approach Congress took in the health law, only about 33 percent would have been in plans getting the extra payments.

http://www.kaiserhealthnews.org/Stories/2011/September/15/medicare-advantage-premiums-fall-next-year.aspx

The Obama administration is countering Republican claims that the Affordable Care Act stole money from Medicare. They are trumpeting the facts that Medicare Advantage premiums are 4 percent lower, and enrollment is expected to be up by 10 percent. We really need to get past the deceptive rhetoric on both sides to understand what really is going on.

The Medicare Advantage program began as a fraud. These private plans were paid 113 percent of the costs of the traditional Medicare program so that they could offer extra benefits to entice individuals away from the public program. Once a sufficient number of individuals joined the private plans, funding for the public program would be slashed and patients would flee into the private plans. Only then would the public learn that the next planned step would be to shift to a Ryan-type voucher (premium support), which would dump much more of the costs onto patients.

The Affordable Care Act included a provision to gradually reduce these Medicare Advantage overpayments. The scheduled reduction for 2012 will be less than 1 percent. But members of the Obama administration have been listening to the insurers and the Republicans. They decided that this very modest reduction might make them more vulnerable to Republican attacks as we enter an election year. So what did they do?

They replenished the reductions with billions of dollars in quality bonuses designed for top tier 4 and 5 star plans, but they expanded the program to include 3 star plans. That way, plans covering 90 percent of Medicare Advantage enrollees would receive additional payments. A quality bonus for almost every plan is nothing more than a blanket payment increase. They have preserved this gift to the private insurers and then have the gall to claim that the programs are stronger and more popular as a result of their “strong negotiations” with the plans! Strength in politics seems to be proportional to the size of the gifts of cash, especially appalling when you realize that this is our tax money.

By the way, how much is that 4 percent reduction in premiums that the Medicare Advantage enrollees will be paying? It averages about $1.48 monthly per enrollee. That tough negotiating sure hit the insurers hard. $1.48! I can picture the insurers leaving the negotiations saying that they sure were hit hard this year, but they hope to do better in next year’s negotiations, as they collapse in hysterics right after the door closes.

One more important fact to keep in mind is that these extra insurance company bonuses are paid partly by our Part B premiums in the traditional Medicare program. Those of us who refuse to join the Medicare Advantage plans are paying higher premiums to buy more patient benefits, more insurer profits and more administrative services for those who have enrolled in the private plans. We now have an official government policy that requires us to pay more and get less if we don’t privatize ourselves!

Dishonesty is so prevalent in politics today that I think I almost understand the graffiti that we saw yesterday while hiking on our ridge trail: “The truth is a lie!”

The following is the prepared text of the testimony given by Dr. Garrett Adams, president of Physicians for a National Health Program, at a Capitol Hill hearing on the topic of “Is poverty a death sentence?” The hearing was conducted by Sen. Bernie Sanders, chair of the Subcommittee on Primary Health and Aging of the U.S. Senate Committee on Health, Education, Labor and Pensions, on Sept. 13 in Washington.

To watch a video of Dr. Adams delivering his testimony, visit the subcommittee’s website and drag the time marker to 49:00. The relevant segment is 7 minutes long.

Others testifying at the two-part hearing included Dr. Sarah Kemble of Massachusetts and Dr. Paula Braveman of California. Their testimony can also be found at the same link.

Sen. Sanders’ report on poverty is available in PDF format here. It was issued on the same day that the U.S. Census Bureau reported that the number of people living in poverty in the United States had increased to 46.2 million, the highest number in the 52 years the bureau has been tracking it. The same report showed that the number of uninsured had climbed to 49.9 million people, which is the highest figure since the passage of Medicare and Medicaid.

Is poverty a death sentence?

Senator Sanders, Senator Paul, members of the Committee,

I am very grateful to Senator Sanders for his sensitivity to the grave health threats that a large portion of the American population currently suffers because of poverty. He does a wonderful service to these people by giving them a voice to our leaders, so that you can better understand the perilous health care situation so many Americans find themselves in because of their poverty.

I dedicate this testimony to all those Americans for whom poverty is, has been, or will be a death sentence. And also to those Americans for whom illness is a poverty sentence.

According to a recent Harvard study, 45,000 Americans die every year because of lack of health insurance, a stark figure. The late Surgeon General Julius Richmond, however, reminds us that “Statistics are people with the tears wiped dry.”

Today I will tell you about some of those people whom I know or have known, all of whom failed or are failing to get necessary life-saving health care because of financial constraints – most impoverished; others not yet impoverished, but who died waiting for approval by a health insurance company of an expensive life-saving procedure that never came or came too late. The first cases I describe are Kentuckians.

Kentucky

David Velten, Louisville. 32 years old. School bus driver. Wife, two young sons. Chronic liver failure. I met David in June 2006. He was initially denied a liver transplant by his insurance company, but due to public pressure, the company relented and allowed it. But it was too late. He died in 2007 several months after the transplant.

Cheryl Brawner, Louisville. 50 years old. Legal secretary, avid bicyclist, friend. Acute leukemia. Advised at Fred Hutchinson Hospital in Seattle to have a bone marrow transplant. Was in remission awaiting approval from the insurance company for the transplant. She waited and waited and waited. Cheryl relapsed and died of her leukemia while waiting for approval.

Clay Morgan, Henry County. Automobile mechanic, owned his own business. Malignant melanoma. Received treatment, improved, thought to be cured, but now was bankrupted. His cancer returned. Depressed and unwilling to bring more medical debt on his family, Clay went into the back yard and took his own life.

Velinda Anderson, “Help Needed for Medicine,” Oak Street, Louisville, Kentucky, March 2011.

Velinda Anderson, Louisville. She was employed. Velinda had had endarterectomy (removal of artery blockage) in her legs, but could not afford the expensive medicine, Plavix, prescribed to keep her arteries open. She had left her usual neighborhood to beg, so that she would not be seen begging by friends. She had not told her daughter that she was doing it.

Grundy County, Tennessee

Grundy County is the poorest county in Tennessee, 95th out of 95. The median household income is $25,619. Sixty-six per cent of school children qualify for free lunch. Nineteen percent of the population is illiterate. Correspondingly, it has the lowest county rank in overall health. The ratio of population to primary care provider is 7,122 to 1, compared to the national ratio of 631 to 1.

Beersheba Springs is on the Cumberland Plateau in Grundy County – Appalachia. We have a vacation home there. In the early winter of 2008, Josephine, an 87-year-old friend, stopped by. She was holding her red, swollen face and was bent over in pain. She had an acute sinusitis that required quick, aggressive treatment. I urged her to get to a doctor immediately. She bounced around several places, but eventually got treated. However, her bill was over $2,000, money she didn’t have, and she did not have Medicare. I decided to establish a free medical clinic for my mountain friends in Beersheba Springs. The Beersheba Springs Medical Clinic, an all-volunteer, not-for-profit clinic opened in November 2010 (www.beershebaclinic.org).

Charlotte Dykes. 64 years old, works odd jobs when able; husband is a carpenter. Peripheral vascular disease. Past history of obstructed mesenteric artery (main artery to intestines) with stent placement in Chattanooga. This spring we diagnosed severe blockage of her right subclavian artery and a 70 percent carotid artery blockage. Surgeon refuses to operate unless she pays up front, because she still has not paid her bill from her previous surgery. Charlotte is a walking time bomb. She will be 65 in December, when she will be eligible for Medicare, if she lives that long. In giving permission for me to tell her story, Charlotte said to me, “You speak out for me.”

Charlene. 54 years old. We saw her in May. She had not seen a doctor in over 20 years. We diagnosed an acute myocardial infarction (heart attack). She was air-lifted to Nashville, treated and discharged, but did not fill her discharge prescriptions (including Plavix – see Velinda Anderson) and did not go to cardiac rehab as directed, because she could not afford either. She is doing very poorly and has a recent dementia, probably due to small strokes.

Doris. 58 years old. She and her husband operated a small local restaurant before her illness forced them to close the restaurant. Estimated annual income: $12,948. Came to our clinic because of a lump in her breast. She had heard we offered mammograms. We diagnosed breast cancer. Because she had breast cancer, she was able to get TennCare to pay for her mastectomy and treatment, but the coverage is only for the cancer treatment.

Billy Campbell. 54 years old. Work: Tree farming and carpentry. Estimated income in 2009: $12,000; 2010: $17,000. No health insurance. Colon cancer, Stage 3. Oncologist recommends PET scan. Hospital refuses to allow it because he cannot pay the $1,500 fee. TennCare denied payment. Disability denied three times. Barbecue benefit to raise money for Billy’s PET scan was last Friday night, Sept. 10, 2011.

Paula. 32 years old. Cervical cancer surgery two years ago. No follow-up, because of no insurance and no money. We arranged for specialist care at no charge.

Bob. Double hernias. Surgeon agreed to fix for $500, but hospital charge will be $8,000. He can’t afford it. His hernias will not be fixed.

Woman with broken arm. 64 years old. No insurance. I saw this woman about three weeks ago. She had a crooked left forearm and limped. She had fallen in March, breaking her left arm and her left leg. She went to a hospital emergency room where she was seen by an orthopedic surgeon, who recommended surgery to properly fix her arm. The surgeon agreed to do it in spite of the lack of insurance, but the hospital refused to allow use of the operating room since she couldn’t pay.

Woman with blood sugar >500 mg percent. The normal value is around 100 mg percent. Hers was a life-threatening level of hyperglycemia. We sent her to a hospital emergency room. She knew she had diabetes. She owned a glucometer, but could not afford the strips to test her blood sugar.

Thank you for this opportunity to speak for those without a voice, who have died or will die as a result of our country’s unwillingness to acknowledge that health care is a human right and to provide affordable, high-quality health care to every resident.

Confidentiality note. All patients with first and last names have given me permission to tell their story. Charlene, Doris, Paula, and Bob are fictitious names. All Grundy County patients, except for Billy Campbell, were seen in the Beersheba Springs Medical Clinic.

Garrett Adams, M.D., M.P.H.

A PDF of Dr. Adams’ testimony is available from the Senate subcommittee.

Originally posted on Medicine and Social Justice blog, Aug. 31, 2011

During the health reform debate, one option we were assured was never seriously “on the table” was “single payer,” or Medicare for All. President Obama, who as a senator had indicated his support for this solution, backed away from it as fast as he could. In this he was undoubtedly encouraged by his many advisors, who have also encouraged bank bailouts, “compromise” on the debt ceiling, etc. (see June 18, 2009,“No Single Payer”: Sebelius – making policy for the powerful).  This is not to say that there were not supporters of single payer within government; there were and are. HR 676, “The Improved and Expanded Medicare for All” act, principally sponsored by Rep. John Conyers of Michigan, had nearly 100 co-sponsors in the House. Sen. Bernard Sanders of Vermont introduced a single-payer bill  in the Senate. Vermont, in fact, has become the first state to move toward a form of single payer on a statewide basis.

As anyone who has been reading this blog for any amount of time knows, I am a strong advocate of single payer. (A few of the many MSJ references: April 28, 2011 Perception and reality of economic inequality; July 22, 2010, Improving quality and access still requires coverage for all;  April 10, 2009, Does the nation need a clear policy on a right to basic health care?).

My reasons for support of single payer are several:

1. It covers everyone. No one is left out. There is no complex system of “these people get coverage this way, those people get coverage that way, and those people (too bad) are left out altogether.”
2. It provides a uniform benefit package. Everyone can get the care that they need, without concern about whether they are covered. In our current system, even many people who are insured have inadequate coverage. In addition, to the extent that the society decides to limit access to unproven or detrimental (see #5 below) or even “too expensive” care, no one gets it.
3. It saves money. Off the top, it saves the profit being taken out of the system by insurance companies and other for-profit businesses. It saves even more money by eliminating all that being spent by those companies to deny care claims and by providers of care to try to get paid (see A Modest Proposal: Bribe the Insurance Companies, August 23, 2009).
4. It puts us all in it together. This is a core method of ensuring social justice. The more educated and empowered among us will work to make sure that they get good care, and this benefits everyone.
5. It provides the basis for ensuring quality, by having a degree of control over what gets reimbursed, and therefore what gets done. It may not ensure quality by itself, but it is almost a necessary component.

In 1964, President Johnson signed the Medicare Bill in Independence, MO, giving cards #1 and #2 to former President Harry Truman, who had fought for national health insurance in the late 1940s and lost, and his wife Bess.Forty-seven years later, Medicare has proven its importance in providing a single-payer program for seniors. It is the largest payer in the country, and the rates that it pays for services determine those paid by other insurers. While expanding Medicare to everyone should be the centerpiece of health policy, it has instead become the target of proposals to cut coverage to those who already receive it, particularly from the right. This has led to a lot of bad ideas from politicians such as Rep. Paul Ryan and Sen. Joseph Lieberman (see Medicare: We need to expand it, not cut it!, July 1, 2011).

The “poster child” for a single-payer system is Canada, which has had it since the early 1970s. Based on the principle of social solidarity, not often apparent in the US, the Canadian federal government set the criteria for the program (which is also called “Medicare”) and the individual provinces set the specific terms and fund it. There is local (provincial) autonomy within the boundaries established by the federal government (see December 14, 2009, Tommy Douglas and the Canadian Health System;  May 27, 2010, Universal Coverage and Primary Care: The US needs both). Several recent articles have addressed the degree to which changes in the primary care system to create “medical homes” in Ontario, Canada’s largest province, have enhanced the quality of patient care, access of patients, lowered cost, and increased the income of primary care physicians (see Rosser et al, “Progress of Ontario’s Family Health Team model: a patient-centered medical home” [1] ). It is critical to note that this Family Health Team program was really only possible on such a scale because Ontario, like the rest of the country, has a single-payer system.

The importance of increasing, or at least not decreasing, the income of primary care physicians relative to other specialist, has been addressed in several other posts. What about all physicians, as a group? The AMA and other physician groups were, after all, largely responsible for the defeat of Truman’s national health insurance program and were major opponents of the US Medicare and Medicaid programs. Surveys by Physicians for a National Health Program (PNHP, see especially “Single Payer National Health Insurance”) have shown increasing support for single payer among the physician community, with universal health coverage being supported by a majority of US doctors in 20 (Support for national health insurance among US physicians: 5 years later[2]).

A new study may help to persuade physicians that single-payer systems are actually in their financial interest. Writing in August 2011 in Health Affairs, Morra and colleagues report that “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”[3] (hyperlink to abstract). The title basically says it all. While both Canadian and US physicians spent time (translated into money!) interacting with insurers, the single payer in Canada and hundreds of payers in the US, about patient benefits and payment, the staff of US physicians spent 10 times the amount of time in such activities as did their Canadian counterparts. The authors estimate the cost to US physicians at $82,975 per physician per year, nearly 4 times the $22,205 cost to Ontario physicians. In addition, these costs fall disproportionately highly on small physician practices, which are more likely to be primary care. They conclude that “If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.”

From a financial point of view, we have an apparent dilemma in the US. The cost of Medicare is very high and creates financial threats to the economy. The reimbursement from Medicare to providers is often too low to make them a desirable payer. But there is a solution. It involves getting control over costs. First, do not pay for harmful or questionable interventions, do not pay major markups to generate excessive profit for private companies, and use the large scale of government purchasing to get good prices for drugs, unlike the boondoggle of Medicare Part D, the prescription drug program in which Medicare pays retail prices to pharmaceutical companies.

The solution is also to emphasize more primary care and prevention (October 18, 2010 Lower Costs in Grand Junction: More Primary Care, Less High Tech). The next steps will be harder, for they will involve making difficult decisions about the cost/benefit ratios of different types of care, particularly as the availability of new, expensive, high-tech interventions provide allure, if not always results.

The way not to do this is for policies restricting access for a part of the population (working and poor people) to be made by another part of the population (big businesses, politicians, and lobbyists) who will not be affected by those decisions. A single-payer system in which we are all covered by the same benefits does not automatically save money, but at least makes it possible.

[1] Rosser WW et al, “Progress of Ontario’s Family Health Team model: a patient-centered medical home”, Ann Fam Med. 2011 Mar-Apr;9(2):165-71.

[2] Carroll A, Ackerman R “Support for national health insurance among US physicians: 5 years later” Ann Int Med 1Apr2008;148(7):566-7.

[3] Morra D, et al, “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”,Health Affairs August 2011 vol. 30 no. 8 1443-1450.

Re ‘Managed Competition for Medicare? Sobering Lessons from the Netherlands,’ by Kieke, Okma, Marmor and Oberlander (NEJM, June 15):

The fundamental flaw in much of the market rhetoric we hear is that health care is not an ordinary product and will never be regulated by market forces.

You can’t exit the market when you are very ill – you buy or die. The doctor not the patient orders the tests and treatments.

The search for information about symptoms is why you go to the doctor. Even a good doctor is sometimes unsure of a patient’s diagnosis or what the long-term costs will be until after some very expensive tests are done.

We have all heard about people with chest pain who were cured with five dollars worth of Maalox and those who needed $100,000 worth of open heart surgery. Americans already face high out-of-pocket costs and it has not controlled health care costs or insurance premiums.

If you are in agony from a ruptured appendix are you going to haggle with the surgeon over his fee on the way to the operating room? The most complex and costly services are the least negotiable.

If open heart surgery was on sale would you have two? The most expensive services are necessary but not really desired like a new car or a Rolex.

Most economists recognize that health care is not a normal product and not subject to the usual market forces. When there is market failure (and health care is a classic example), then the second best solution, regulation, is needed.

The health care systems wit the best outcomes for the least cost are all highly regulated or socialized. (See the Commonwealth Fund data on this fact.) Even here in the U.S. the best quality at reasonably low cost is being turned out by the VA, a completely socialized system.

We already have a national health insurance system that works for the sick elderly and disabled called Medicare. Medicare spends only 3 percent on insurance overhead vs. private insurance which regularly spends 20 percent or more. We should improve and expand Medicare to all. Multiple studies by solid health economists suggest that we could save over $400 billion by the simplicity of this system. This is enough to cover all the uninsured and improve coverage for all the rest of us.

As noted by the authors of this paper, an unanticipated outcome of the Dutch competition was increased cost due to complexity.

Every year around the Fourth of July, amid the flag waving and fireworks, I come across an article or two blaming patriotism for the ills of civilization. I agree with much of the criticism. A constant obsession with being “the best in the world” makes us both arrogant and unrealistic. Believing we can be truly healthy—economically, environmentally, or otherwise—without considering the roles and needs of other nations is not only immature but dangerous.

As I often do when confronted with a loaded word, I looked up “patriot” in my old Merriam Webster dictionary. I was struck right away by the short, simple definition: “love for or devotion to one’s country.” I’m sure you know it came originally from the Latin for father, pater. Interesting, since the earth parent is usually a maternal one. The paternal face of country has more to do with the political structure, historically a masculine creation, than the land itself.

What if we imagined our country, in both earthy and political nature, as a parent? I don’t mean to invoke the over-protective helicopter version. I’m talking about our formation as persons—the various influences that eventually make us who we will be. And how about our reciprocal duty to our parents, as they age and sometimes need us to care for them? Could we consider how we are serving in that role to our nation, now well over 200 years old?

I’ve worried sometimes, while advocating strenuously for Medicare for All (including visitors and immigrants), that I’m taking a sort of parochial view. It seems a little selfish to spend so much effort lobbying for my fellow country-people, when much of the world fares far worse in life expectancy. I wonder if I should be doing something more globally relevant instead.

But all this thinking about land and politics, fathers and mothers, and caring for one another took me in an unexpected direction. We aren’t patriotic enough. If we were more patriotic (loving, devoted), and followed the principle of loving other (countries) as ourselves, maybe we’d do better. There’s no need to hold back our love for this land, its history or its people. We don’t have to be blind about it either. In fact, we owe a special duty to address the errors of those we love. I have a deep love for my state, Alabama, despite its sometimes recalcitrant and difficult ways. It’s ok to love a city, a certain neighborhood, a particular tree. We can all start where we are, then extend ourselves outwards, as in the spiritual practice of lovingkindness meditation.

Let’s love our country more. Tell Congress we want to pay for our nation’s healthcare and not be forced to give protection money to private insurers. With the savings, we will be in better condition to bring resources to those other (also beloved) lands in need. We don’t have to limit the borders of our patriotism. Everybody in. Nobody out.

http://pippaabston.wordpress.com/2011/07/06/medical-patriotism/

It was December. I got a dismaying e-mail from the American Academy of Neurology.

The AAN was conducting a membership survey to inform the Academy’s 2011 advocacy agenda. “We want to hear from you about the challenges you and your patients are facing,” the message read.

To my chagrin, I did not feel that my priorities or values were represented in the choices presented on the questionnaire. The items on the menu were all decidedly “thinking INside the box” of business-as-usual health care:

From the list below, please select up to three issues that you believe should be top legislative priorities for the AAN in 2011:

* Adoption of guidelines to minimize concussive injury during sporting activities
* Inclusion of neurology in the E/M bonus (created by the 2010 health reform law)
* Medical liability reform
* Neuroimaging practice issues
* Reimbursement for telemedicine
* Remedy for the loss of Medicare consult codes
* Right to privately contract with and balance-bill Medicare beneficiaries

I felt sure many other neurologists would feel the same way as I did about the limitations of this list. I appealed to my colleagues at Physicians for a National Health Program for help and was quickly supplied with a list of e-mail addresses of PNHP neurologists.

I e-mailed this group and suggested they send a “write-in” vote for single-payer national health insurance. I wrote to 113 members and, though I did not ask for any response, got back 14 personal replies from neurologists in eight states, all of whom “wrote in” votes for single-payer health reform to the AAN.

After this heartening response, I had a series of conference calls and e-mail exchanges with several of my colleagues, including Drs. Rachel Nardin and Deborah Leiderman, to discuss how we might put additional pressure on the AAN to take up our issue.

We did not expect the Academy to take a stance in support of single payer. We decided that a more sensible “ask” would be to request that the AAN poll its members about their views on health care reform.

Citing polling data showing robust, majority support for national health insurance, we wrote a letter to the Academy suggesting it conduct such a survey “so as to faithfully be able to represent its members’ voices in the national health care debate.”

Over 30 neurologists from 14 states signed the letter, which we sent to the president of the AAN, Dr. Bruce Sigsbee, and other key members of AAN leadership.

Dr. Sigsbee replied to our letter, saying that “AAN members have diverse views ranging across the spectrum of the government involvement in the health care system,” adding, “We recognize and respect the differing views and feel it best to focus on those issues where a majority of our members feel we can have the most impact.”

In short, he did not agree to our request.

Nonetheless, we believe efforts such as ours will keep pressure on bodies of organized medicine and keep single-payer advocacy “on the map.” Furthermore, the sign-on letter allowed a disparate group of neurologists to raise our voices together for what we believe in: health care as a human right, with everybody in and nobody out.

Laura S. Boylan, M.D., is clinical associate professor of neurology, New York University School of Medicine; attending neurologist, Department of Veterans Affairs; and board member, Physicians for a National Health Program – N.Y. Metro chapter. Dr. Boylan’s institutional affiliations are provided for identification purposes only; the views expressed are hers alone.

Your editorial proclaiming the success of the Massachusetts health care reform (“Health reform in Massachusetts,” May 21) is off the mark. The U.S. Census Bureau, the Massachusetts Health Reform Survey and the Massachusetts Department of Revenue find that the number of uninsured has fallen by only about half, to around 5 percent.

This modest result has not been achieved with “minimal fiscal strain.” The reform has been propped up by the infusion of federal dollars and use of the state’s “rainy day funds.” The state has had to cut some Medicaid benefits, allow further cost-shifting onto patients to keep premiums down, and shift some legal immigrants off the state subsidized insurance into an inadequate, but cheaper, for-profit plan.

The reform has done much more to increase access to insurance than to increase access to care. This may explain the Harvard School of Public Health poll finding that among those actually affected by the reform, more believed the reform had hurt than helped the uninsured.

As you acknowledge, the reform has done nothing to address health care costs, which continue to escalate at alarming rates. Although the governor’s hope that accountable care organizations and other payment reforms will solve this problem, this is based more on faith than solid policy evidence.

As a physician who cares for some of the Massachusetts residents who remain without insurance, I see the needless suffering that persists here. I struggle to provide care in a fragmented system in which access is dictated by the financial interests of competing insurers. I want better for our nation. Single-payer health care reform, with truly universal coverage and proven mechanisms to control costs, is our best hope.

Dr. Rachel Nardin

Chief, Division of Neurology, Cambridge Health Alliance; Assistant Professor of Neurology, Harvard Medical School

Karen Green Stone

My name is Karen Green Stone from Bloomington. I own 15 shares.

Since last year’s meeting it’s estimated that another 50,000 people have died in the United States because they are uninsured. That equals the entire population of Kokomo [Ind.].

I’d like to start with comments made by friends and strangers I’ve talked to about coming to this meeting. “Give the bastards hell,” one said. “Go get ’em,” said another. “I hate Anthem,” a friend told me. Still another: “Don’t get me started.”

After hearing Wendell Potter speak in Bloomington on his book tour (I’m sure you all know Wendell Potter) a friend said to me, “I sometimes thought I was crazy, a conspiracy theorist – now I know they really are evil.”

I read and talked to Wendell about his book, “Deadly Spin.” What stirs my anger the most is the stealth and perversion you’ve used to shape public opinion. Your PR campaigns have nurtured fear and confusion in the minds of reasonable and caring Americans.

I imagine it must be very difficult hold steady the concept of “I’m a good person and I work for a corporation that by its very nature lacks compassion and is indifferent to suffering.” But good and intelligent people can sometimes fall into a trap.

Everyone in this room knows that it’s all about money and power. We know WellPoint’s sordid history of rescission, rigged software, cherry-picking of healthy patients and denial of care. We know about the barriers you build, making it so difficult that people give up or die fighting with you.

I hope that one or some of you in this room who feel the stirrings of having sold out will find the courage to go public with inside information because your business model is taking down America.

Angela, it takes 285 public school teachers in Indiana who earn an average of $47,000 a year to equal your 2010 compensation package of $13.4 million.

Would you kindly tell us why you are entitled to so much more than them?

The following remarks were delivered by Dr. Young at a press conference in the Illinois State Capitol in Springfield, Ill., on April 11, 2011, convened for the purpose of announcing the introduction of state Rep. Mary Flowers’ state single-payer legislation, the “Illinois Universal Health Care Act,” H.B. 311. His remarks and those of several others are available on video. A more complete account of the events in Springfield that day can be found at the Illinois Single Payer Coalition.

I have to believe that all of you enjoyed the presentations that preceded me as much as I did. They were spectacular, because not only are they speaking the truth, but they indicate the coalition that is going to make single-payer health reform happen.

We’re not there yet, but there are very important gains in this country and in this state. In Illinois, no small thanks to state Rep. Mary Flowers for her spectacular leadership in the Legislature, we are making advances, as is evident by those present here today.

In this country we have states like Vermont actually electing governors and representatives and senators who run on a single-payer program. That’s new.

Now, the basic problem is not complex or too difficult for anybody in this room to figure out. The cost of our health care system last year was – brace yourself – twenty-seven hundred billion dollars, or $2.7 trillion. To give you a comparison, at the end of World War II, we had a health system for the nation that cost $22 billion. Now we are spending more than a hundred times that much and, as has already been indicated, not doing very well at all in terms of medical outcomes.

These days, the banter is all about the cost of government and the need to cut down expenses. Much of that I think, is cynical politicking, but if you want to save money, Mr. Politician – Democrat or Republican – enact a single-payer system. You’ll immediately reduce costs and at the same moment give care to all the many tens of millions of people who are either not covered or who are covered inadequately.

I have optimism. I’ve been at this a long time, and I sense we are getting close to victory. On the other hand, I don’t think that it is going to be easy. It’s going to take a movement because the interests of private companies who profit drastically from this system are going to hold tight and they have all kinds of schemes to discredit and confuse the public.

Take for an example the very important health notion that patients should, with their doctor, toward the end of life discuss the kind of treatment they want. Do they want a lot of life-saving methods or do they want to be made comfortable? You know the issue.

This gets translated into “death panels.” The cynicism of that can’t be exaggerated, because you are dealing with people’s lives, with their elementary dignity and needs. And so it goes in the so-called debate over “government-run health insurance” and “socialized medicine” – all these words that they think the American people are automatically going to negatively react to.

I think we’re at the beginning of a new era. I hope I can check this out with all of you in a relatively short period. I think the events in Wisconsin, where the people said, “No more, that’s enough,” and “You can’t take away our elementary rights to bargain collectively or indeed to have government services,” I think that is going to be a turning point in American history. I am counting on it, but your presence here is part of that process.

We’re using our first amendment rights today to petition the Legislature for a redress of grievances. And, the health care system in Illinois is in grievous shape, and we want to change it. We want single-payer, national health insurance.

I’m thrilled to be at this podium with so many colleagues. Let me close on a very up note. I went to Northwestern also. But I’ll tell you a secret: it wasn’t in this century!

I’m proud that my colleagues at Northwestern are in the fray and are so articulate about their desire to serve the people and not be turned into cogs and money-making machines for the insurance companies.

That’s really exciting because one of the arguments used by supporters of the private health insurers in Vermont, where the people did indeed elect a governor and both houses of their Legislature on a single-payer program, was embodied in ads saying, “Doctors will flee this state if you enact this terrible thing.”

Well, I am pleased to tell you all, if you haven’t heard it already, that a week an a half ago on a Saturday, 250 medical students, wearing their white jackets, came to Montpelier, Vermont’s capital, to demonstrate for single payer now and to say they’d be happy to practice in this state if it enacts a single-payer system.

As a doctor for many years – way too many – I can tell you that it’s a conservative profession, but the good news is that the majority of physicians, not to mention medical students, now see national health insurance as the answer.

So I congratulate you all for being here as part of this movement. Somebody it before me, but I’ll reiterate: it’s going to take a movement to move this Legislature and move the Congress, but it’s going to happen. Thank you.