Why I got arrested

Posted by on Thursday, Oct 29, 2009

From Matt Hendrickson

My name is Matt Hendrickson, I am an Emergency Physician and the Vice Chair of the Physicians For a National Program, Los Angeles Chapter. Yesterday I was arrested at the Cigna offices in Glendale, California.

After getting last second jitters to join the 12 arrestees in the “Patients Not Profits” event on October 15 at Anthem Blue Cross in downtown Los Angeles, I committed to joining 6 other volunteers for yesterday’s civil disobedience action to protest the harmful practices of private health insurance. Our group included a retired nurse, a Cal Tech Physics doctoral student, an unemployed clerical worker, a computer programmer, a labor organizer and a member of the California Democratic Party Board of Directors.

We participated in three training sessions where we learned about satyagraha (Gandhi’s term for soul force), and “the sword that heals” (Martin Luther King, Jr.): power in society flows not from guns or positions of authority but from the consent and cooperation of the people. That power is unleashed by the combination of refusal to use force to harm one’s opponent and the willingness to make deep personal sacrifices and even suffer for one’s causes.

The action was organized by Mobilization For Healthcare, a one month old organization cobbled together from the financial support of Healthcare-Now! and the civil disobedience expertise of the Center For the Working Poor. Center for the Working Poor is a shoestring nonprofit of young men and women that live communally in an old Victorian home in downtown Los Angeles and take inspiration from the teachings of Reverend James Lawson, the architect of the Civil Rights Sit-In Movement.

Mobilization For Healthcare’s first action was on September 29th, and since then there have been over 20 sit-ins with approximately 100 arrests. Ten other cities had actions today, another ten cities will do nonviolent civil disobedience over the next 6 days. Beyond the next week, Los Angeles is already planning their third action with a new wave of volunteer arrestees to include more physicians and reportedly local politicians.

These actions are unlike any single payer events I have seen. Many of the activists are much younger. There are drums, singers, and street theatre (billionaires for wealthcare). And the message is not muddied by a divided approach between the merits of government financing and a criticism of the status quo. For these events there is one sharp focus, apparently guided by consultation with George Lakoff: private insurance is the real death panel.

With my arrest yesterday, and Dr. Flowers probable arrest today, maybe it is time for our organization to consider a new phase to our advocacy. The image of physicians in white coats being escorted away from insurance offices in handcuffs on a daily basis could bring an unexpected and profound new voice to this reform debate. The voice of physicians like Dr. Hochfeld who are Mad As Hell at how the political process has ignored the heartbreaking reality of our broken healthcare system and refuse to be complicit in the meaningless political solution.

In my case the day was exhilarating. The group of seven entered the Cigna offices lobby and were met by a phalanx of stormtrooper-like officers who blocked our route to the elevators. So we sat in the lobby facing them and with cameras flashing a two hour song and chant filled standoff ensued before we were warned and then briskly handcuffed and carted off to the jail for processing. Four hours later we were released without a bail charge or fine but with a misdemeanor charge for Civilian Arrest Trespassing that will be defended at our court date by volunteer Civil Rights Attorneys.

I will leave to those physicians that are admirably more cautious than I am the job of researching the possible consequences of this misdemeanor if the charges are not dropped, it didn’t matter to me. In my mind I was making the right decision for my patients and for my profession.

It is a personal decision and every physician knows when it’s the right time if ever for them to make that sacrifice. But I believe that a relatively small sacrifice -a few hours, maybe a night in jail- in exchange for broad media exposure to dramatize the profound harm of the private insurance industry on the practice of medicine is an irresistible opportunity.

Weiner single payer amendment tanks

Posted by on Thursday, Oct 29, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Nancy Pelosi starts clock on House health bill

By Patrick O’Connor and Chris Frates
October 29, 2009

(House Speaker Nancy Pelosi) backed down from a deal granting liberals a vote to establish single-payer government-run health care. She cut the deal with New York Rep. Anthony Weiner to break a last-minute logjam on the Energy and Commerce Committee. But, in the end, party leaders were concerned the final cost would be astronomical and the vote would fail to garner votes from even half the caucus.


What the… !?

The ethics of health care reform

Posted by on Wednesday, Oct 28, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

“Making Sense of the Health Care Debate”

A round table discussion of health care reform
University of California at Irvine
The UCI Interdisciplinary Center for the Scientific Study of Ethics and Morality
October 27, 2009

Comments of Don McCanne, M.D. (from memory, edited and abridged):

I’ll be brief because I want to make only one very simple point: An ethical health care system is designed to take care of patients. What could be more obvious? If the health care system is doing its job in taking care of patients then the health care system itself is being taken care of. Special interests legitimately involved in health care delivery will do just fine.

Although this principle seems very obvious, it hasn’t been guiding the process in Washington, DC. Our politicians are designing a health care system that is taking care of the private insurance industry. Patient care is secondary, as it must conform to the private insurance model.

As Senator Joe Dunn just said, legislation is 10 percent principles and 90 percent politics. Congress is providing us with a political solution rather than a solution based on sound health policy science.

We were told that we would have health care reform that would cover everyone, and that costs would be controlled, making health care affordable for each of us. Yet when they insisted that reform be based on private insurance plans and that the budget be limited to $900 billion over the next ten years, they realized that at least 20 million people could not be insured under this proposal. Likely it will be many more, especially after four more years of health care inflation before the basics of this plan are even in place. And since there are no effective measures for controlling costs, health care will be even less affordable.

The limitations imposed have resulted in such bizarre policy proposals as granting waivers to individuals to exempt them from the fines that would be imposed for committing the criminal act of being uninsured.

A fundamental flaw of their proposal was to try to craft reform based on a package of benefits in a private insurance plan that has a premium assigned to it. That premium plus the out-of-pocket expenses must cover the average family health care costs of $16,771 (Milliman Medical Index). With a typical family income of perhaps $60,000, those costs now create a financial hardship for families, especially those at income levels where the subsidies phase out.

By designing reform that primarily benefits insurers, the most productive sector of our society – middle income Americans – is going to be the hardest hit by the adverse consequences of this legislation.

Since this is a forum on ethics, I have to conclude that our legislators, by failing to place the patient first, compromised ethics when they crafted this reform.


The actuarial squeeze on low and middle income families

Posted by on Tuesday, Oct 27, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Provision Under Consideration for Merged Senate Health Bill Would Harm Needy Families

By January Angeles and Judith Solomon
Center on Budget and Policy Priorities
October 26, 2009

A family of three earning $27,465 a year before taxes — that is, at 150 percent of the poverty line — would have to pay $1,318 a year for health coverage under a proposal that Senate negotiators are considering for a merged health reform bill that they would bring to the Senate floor.

This is related to efforts that Senators working on the merged bill are making to cap the cost of insurance premium contributions at 10 percent of income for households that earn between 300 and 400 percent of the poverty line, rather than at 12 percent of income as under the Finance Committee bill. To help pay for this change, they reportedly are also considering increasing the amounts that very low-income households would be required to pay.



Trends In Underinsurance And The Affordability Of Employer Coverage, 2004-2007

By Jon R. Gabel, Roland McDevitt, Ryan Lore, Jeremy Pickreign, Heidi Whitmore and Tina Ding
Health Affairs
June 2, 2009

Health plans covered slightly fewer expenses in 2007 than in 2004, but out-of-pocket spending grew more than one-third because of growth in overall health spending.

Underinsurance rose from 2004 to 2007 as the actuarial value of employer-based health insurance declined slightly, from 81.4 percent of the bill to 80.1 percent. The major change in benefit design during these years was an increase in the percentage of plans with deductibles and an increase in the average deductible level.

In the United States, if you are sick and earn a modest income, then you are probably underinsured–even if you have employer-based health coverage.


The best private insurance available today – employer-sponsored health plans – have an actuarial value of 80%. That means that the insurance pays 80% of the covered costs of health care and patients are responsible for the other 20%. Patients also are usually responsible for out-of-network services and for services and products that are not benefits of the plans.

The Health Affairs article by Jon Gabel and his colleagues shows that plans with an 80% actuarial value are not providing adequate financial protection to individuals with modest incomes who need health care. Having a plan with an 80% actuarial value can place you in the ranks of the underinsured.

Basic coverage under the proposals before Congress would provide an actuarial value of 65% or 70%. That means that the patients would be responsible for the remaining 30% or 35% of health care costs, although the proposals would limit the total amount for which the patients are responsible under the plans. Patients also would be responsible for out-of-network services and for services and products not covered by their plans.

If there is a cap on out-of-pocket spending, then why should the precise actuarial value make difference? Simply, the lower the actuarial value, the greater the likelihood that the patient will have to spend the full amount up to the cap. Thus more individuals will be negatively impacted. Also, the amount of the cap makes a very big difference. The proposed caps on out-of-pocket spending, when added to the patient’s share of the premium, create a financial hardship for most low and middle income individuals and families.

Members of Congress are particularly concerned about the high costs for those at income levels wherein the subsidies supporting the premiums are phased out. Not only do they understand that making health care unaffordable is not wise policy, but they also understand the backlash that would likely occur when the most productive sector of our society finds out what hit them.

The report from the Center for Budget and Policy Priorities demonstrates how desperate our legislators are to find a way out of this highly flawed financing proposal that hits their base supporters the hardest. To soften the impact on middle income individuals and families, they are investigating a proposal to increase the amounts that low income families would have to pay, even though they already can’t pay the current levels proposed. Perhaps they calculate that, at election time, bankrupting individuals without a political voice is a safer than facing a backlash from the base supporters.

Is health insurers’ profit 2% or 22%?

Posted by on Monday, Oct 26, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Health insurers’ profits 35th of 53

By Calvin Woodward
The Washington Post
October 26, 2009

Health insurance profit margins typically run about 6 percent, give or take a point or two.

Health insurers posted a 2.2 percent profit margin last year, placing them 35th of 53 industries on the Fortune 500 list. As is typical, other health sectors did much better – drugs and medical products and services were both in the top 10.

Leading the list: network and other communications equipment, at 20.4 percent.



October 26, 2009

Health care plans – net profit margin: 3.3%



American Medical News
August 24, 2009

Medical loss ratios of largest publicly traded health plans:
Average 85.2% (non-weighted, range 82.9% – 86.8%)


In simple accounting terms, profit represents the difference between gross revenues and the cost of producing and marketing the products or services sold. So what is the product that the private insurers are selling us? Administrative services.

Unlike most other businesses, the revenues of the private insurers include our own funds that essentially are held in trust for the eventual payment of medical claims – currently 85.2% as represented by their medical loss ratios. Their business costs relate strictly to their product – the administrative services – currently 14.8% of their revenues. Thus their profit margin, to make sense, should be calculated based on their business model of providing us administrative services, but not on the funds held in trust which involve negligible expenses but which provide them with long term investment income. (Profit statements for the notorious financial services industry should also be adjusted accordingly since that is also our money that they are jerking around.)

The 3.3% profit margin reported by Morningstar includes the funds held in trust, but if adjusted to include only all costs of their legitimate business operations of producing and marketing their administrative services then their profit margin is actually 22.3%. That moves them into first place on the Fortune 500 list of profitable firms, in front of the network and communications equipment industry (20.4% profit).

To be realistic, playing with these numbers does not change the fact that eliminating these profits would have only a very small direct impact on our total national health expenditures – saving less than 1% of our health care dollars. What would have a tremendous impact would be to eliminate an industry that has the incentive of a 22% profit margin on a product that is designed to reduce our access to the health care that we need, not to mention a product that places a costly administrative burden on our health care delivery system. Eliminating the private insurance industry could have a hugh direct impact on our health care spending – diverting perhaps $4 trillion over the next ten years from administrative waste, and redirecting it to patient care.

We need to take heed of this comment in today’s Los Angeles Times:

“As President Obama’s push for a healthcare overhaul moves toward its final act, the oft-vilified health insurance industry is on the verge of seeing a plan enacted that largely protects its financial interests.”


Baby boomers and cancer: storms ahead

Posted by on Thursday, Oct 22, 2009

Book Review
“The Cancer Generation: Baby Boomers Facing a Perfect Storm,” by John Geyman, M.D. Common Courage Press, 2009. Softcover, 303 pp., $18.95.

By A.R. Strobeck Jr.

In “The Cancer Generation,” Dr. John Geyman, physician and professor emeritus of family medicine at the University of Washington, focuses on the baby boomer generation in the United States and the virtual tsunami of cancer cases that is expected to hit this 79.5-million-member demographic as more of its members move into their “golden years.”

Geyman says he aims to examine “the changing landscape of cancer in the U.S., including the extent to which the marketplace fails patients with cancer care.” He takes a hard look at how well the present state of cancer care – particularly the financing of medical services – measures up to the task of providing quality, compassionate care to those who need it.

While he draws upon the latest academic research and the book is heavily footnoted, the material is presented in a popular, accessible way, including with the abundant use of tables and graphs.

The picture he draws is not pretty. The author believes that the outlook for cancer care is bleak, largely due to the unregulated “free market” economic policies that have come to dictate both access to, and delivery of, health care in the U.S. These policies have given rise to an astronomical increase in the costs of cancer care, with treatment costs are now rising by 20 percent each year. The rising costs are putting effective care out of reach of millions.

This problem is expected to worsen, the author says, noting that the Institute of Medicine projects the number of cancer cases will double between 2000 and 2050. Meanwhile, the annual cost of treating cancer is projected to reach $1.1 trillion by 2023, more than five times what we spend today.

As a result, the aging of the U.S. population “will lead to an increasing cancer burden, both for individuals and their families as well as for the health care system itself.”

Geyman acknowledges that treatments for cancer have improved, and today’s care can be effective in many cases. He points to the dramatic increase in the survival rate among children diagnosed with cancer, for example.

But lack of health insurance, or poor quality insurance, prevents people from getting access to and obtaining proper care. The chief culprit here, he says, is the private health insurance industry, which is more concerned with increasing its profits than in assuring access to care.

More generally, however, he believes that our present market-driven health care system cannot meet the coming surge in cancer cases without drastic changes in its structure, access, delivery and methods of financing.

Geyman sees a blind faith in technology in the U.S. as fueling an explosion of new technologies, even though there is much uncertainty as to the safety and efficacy of these innovations. Unfortunately, he asserts, due to the high stakes that come with cancer, patients facing it are “especially vulnerable to accepting treatment at whatever the risks or costs.” Thus the marketplace is “setting cancer policy by default,” i.e. most of our health care dollars are going into treatment and far too little into prevention.

Cancer survivors face special challenges, he writes. They are less likely to be employed. They face three kinds of barriers to care thrown in their way by private insurance: availability, affordability and adequacy. And if these barriers are not enough, private insurance companies sometimes will go to even greater lengths to deny coverage to those afflicted.

Survivors lucky enough to have insurance face much higher co-payments. In addition, insurance firms try to cap coverage or otherwise place limits on the amount of treatment. As a result, a cancer diagnosis is often a prelude to financial crisis and bankruptcy.

Cancer survivors without insurance often find it difficult to see a doctor or to have a regular source of care. Geyman notes that it is no wonder that uninsured and Medicaid patients often have cancer at a more advanced stage when it is diagnosed. In addition, most cancer survivors often have serious co-morbidities such as heart disease or diabetes, which also go untreated at a disproportionately higher rate.

Geyman argues that everyone needs accessibility to doctors if the mortality rate of cancer is to be reduced. Unfortunately, the policies of the private health insurance industry are heading in the opposite direction, leading to uncontrolled inflation of costs; growing unaffordability of premiums; decreasing levels of coverage; a bloated bureaucracy, contributing to the waste of 31 cents of every U.S. health care dollar on administrative costs; a shrinking market of only 59 percent of employers now offering health insurance; ineffective state and federal regulation; and growing insecurity and hardship in the general population.

Racial disparities also continue to take a heavy toll: for example, cancer mortality rates are 35 percent higher for African Americans than whites.

What’s his prescription for a cure? As step No. 1, Geyman recommends establishing a public health insurance system such as single-payer Medicare for All. Such a system would provide health care services “based on medical need, not ability to pay, ” and would “eliminate much of the inefficiency and waste of the private insurance industry and actually cost employers and individuals less than we are already paying for insurance and health care.”

He outlines additional measures like establishing a national, evidence-based clinical effectiveness program; more funding for cancer research; and the strengthening of the nation’s cancer workforce, especially in primary care and geriatric oncology.

Finally, Geyman reminds us of the ethical issues surrounding cancer care, citing Dr. Martin Luther King Jr., when he said, “Of all forms of inequality, injustice in health care is the most shocking and most inhuman…. Although social change cannot come overnight, we must always work as though it were a possibility in the morning.”

Reading and acting on this book will help bring about that better day.

A.R. Strobeck Jr. worked for many years in health care administration. He resides in Chicago.

Kitzhaber on health care costs

Posted by on Wednesday, Oct 21, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Dr. John Kitzhaber’s Unorthodox Ideas On Reforming Health Care

By J. Duncan Moore Jr.
Kaiser Health News
October 21, 2009

Q. Why are you running for governor again?

A. Costs for health care are going to continue to escalate and states will be overwhelmed. Whatever comes out of Congress this year is not going to have much impact on overall costs.

Q. How do you feel about the reform effort in Congress?

A. I’m not optimistic. I think Washington, D.C., is really badly broken. The discussion today is not about health care, it’s about both parties trying to position themselves for future majorities.



Evaluating Health Care Plans: An Analysis of the Short- and Long-Term Fiscal Implications of Reform Plans

US Budget Watch
(supported by Pew Charitable Trusts)
October 19, 2009

Unfortunately, each bill making its way through Congress has employed at least one of these gimmicks:

* Timing Gimmicks
* Loopholes
* Omissions
* Bogus Offsets

… many provisions within the bills… would result in increases of overall health care costs.


The five reform bills passed by House and Senate committees will not control health care costs, and yet these are to be merged into one bill – that will not control health care costs.

What is the worst that could happen?

The second worst is that the final bill could be defeated and everyone would walk away with yet another failed attempt at reform. (Everyone would understand that very soon we would have to return to start over since the status quo is totally unacceptable.)

The very worst is that this bill could pass and everyone would walk away insisting that we have successfully reformed health care when all we have done is to establish an unnecessary and unethical ten-year long experiment that will cause financial hardship, physical suffering and even death – adverse outcomes that could be prevented with reform based on policy evidence rather than markets.

The goal of completing action on this bill before Christmas, pass or fail, and then walking away is not acceptable. We must set this bill aside and start fresh with a model that would prevent yet another decade of unnecessary grief. That model, of course, is an improved Medicare for all.

Insurance promotes awareness and control of chronic disorders

Posted by on Tuesday, Oct 20, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults

by Andrew P. Wilper, Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein
Health Affairs
October 20, 2009

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Unrecognized or undertreated disease places uninsured people at risk for costly, disabling, or even lethal complications. For instance, many cases of kidney failure, blindness, and amputation are preventable through good diabetes control. Hypertension control is the major strategy used to combat stroke.

For the uninsured, recognition of these three conditions lags behind that of people with health insurance. Insuring the uninsured may improve care and reduce rates of disabling complications and death for Americans with these chronic illnesses.


This study confirms that being insured not only improves the control of chronic diseases, it also improves the diagnosis in individuals who are not even aware of their disorders. Insuring the uninsured can delay or even totally prevent the disastrous complications of these chronic disorders.

Current legislative proposals would leave perhaps tens of millions of individuals without insurance coverage. We cannot afford to complete the reform process until we establish policies that would cover absolutely everyone.

Our representatives in Congress need to halt the process now while they take another look at a single payer national health program – an improved Medicare for all – which actually would cover everyone. The House will have a chance to do so in the next few weeks when Rep. Anthony Weiner introduces his amendment on the House floor that would replace the language of the reform bill with the language of the single payer model.

Those who have not done so already may be interested in watching the seven minute video of Rep. Weiner’s statement when he previously introduced the single payer amendment in committee:

By Kip Sullivan, JD

The New York Times reported on Saturday, October 17, that Sen. Ron Wyden (D-OR) is warning his constituents that the “public option” is not going to be available to the great majority of Americans. No one who has actually read the Senate health committee’s “reform” bill or the House “reform” bill (HR 3200) disputes this. According to the Congressional Budget Office, the “option” will be available only to about 30 million people, or about one American in ten. As the Times put it (slightly inaccurately), the “option” in the Democrats’ legislation “would be out of bounds to the approximately 160 million people already covered through employers.”

Does the public understand this? According to Wyden, they don’t. Wyden says his constituents are shocked when they are told the “option” will not be available to the vast majority of Americans. When he began informing his constituents about this truth last summer, “They nearly fell out of the bleachers,” he said (“And the public option is….,” New York Times, October 17, 2009, A10).

Democrats and “option” advocates should pay attention to Wyden’s observation. Wyden is saying, in so many words, that “option” advocates, with help from the media and the blogosphere, have fooled the public into thinking everyone will be eligible to buy insurance from the “option,” and when the public finds out this isn’t true, they’re not going to be happy.

I was not surprised by Wyden’s observation. I have written several papers warning the public that they have been the object of a “bait and switch” campaign by the leadership of the “option” movement. The “bait” in this campaign was the original version of the “option” promoted by Jacob Hacker. This version would have created an enormous public program that would have insured half the non-elderly population. Among several provisions of this first version of the “option” that would have ensured large size was one that said the “option” had to be available to all non-elderly Americans. The “switch” occurred when Democrats on the Senate Health, Education, Labor and Pensions (HELP) Committee and three chairmen of House committees drafted legislation that would create a very small and weak “option.” One of the provisions in the Democrats’ legislation that ensured their version of the “option” would be weak was a provision limiting subsidies and eligibility for the “option” to a small fraction of the population, namely, the uninsured and employees of small firms.

After reading Wyden’s warning, I examined over 50 polls to see if any pollsters had bothered to investigate the issue Wyden is raising. It would be interesting, I thought, to see if (a) pollsters had allowed themselves to be fooled by the bait-and-switch campaign for the “option” and (b), to the extent that they hadn’t been fooled, what did they find out about how badly the average American had been fooled?

I discovered that the nation’s best known polling firms have allowed themselves to be fooled. Pollsters are asking the public the wrong question. They are asking the public to comment on Hacker’s original version of the “option” (the “bait”), not the actual “option” proposed in the Senate HELP Committee bill and HR 3200. Not surprisingly, the polls tell us very little about whether the public thinks the “option” will be available to everyone or to just a small minority.

Pollsters are asking about the “bait,” not the actual “option”

Pollingreport.com is a widely used source of polling data. I don’t know how they select the polling firms they report on, but I do know many of the most recognizable polling firms appear on their website. On October 17, I visited their website, clicked on their “health policy” section, and read every one of the 52 polls listed for the period June 1 to October 8. I selected June 1 as my beginning date because congressional Democrats did not publish drafts of their bills until mid-June. October 8 was the date of the latest poll listed on Pollingreport.com as of October 17.

Twenty-three of these 52 polls asked a question related to the “option.” (In a few days, I’ll post a listing of these polls and the questions they posed in an appendix). Of these 23 polls, the questions in one of them conveyed no information about who would be eligible to participate in the “option.” The remaining 22 polls all posed questions that stated explicitly or implicitly that all Americans would be eligible to participate in the “option.” One of these 22 polls asked a follow-up question (it was a follow-up to a question asserting that the “option” would be universally available) that informed respondents that the “option” might turn out to be available to only a small fraction of the populace. None of the other polls gave so much as a hint that the “option” would be available to only a small fraction of the population.

Three of the 22 polls that conveyed some information about who would be eligible to participate in the “option” explicitly stated the “option” would be available to everyone.* For example, the September 17-20 NBC/Wall Street Journal poll asked: “Would you favor or oppose the government offering everyone a government-administered health insurance plan – something like the Medicare coverage that people 65 and older get – that would compete with private health insurance plans?” (emphasis added)

The remaining 19 polls (of the 22 that conveyed information about who could participate in the “option”) used language that would lead most readers to infer the “option” would be offered to everyone. The most common method used by these 19 polls was to state (1) the “option” would be (2) “like Medicare” and would (3) “compete” with the insurance industry. Referring to the public program as “an option” without qualification implies the program will be universally available. Comparing the program to Medicare (a program that is available to almost the entire elderly population) also implies universality. And depicting the program as a competitor with the “insurance industry” or “health insurance companies” also connotes universality. Any one of these three features – employing the word “option,” comparing the “option” to Medicare, and depicting the “option” as competing with the entire insurance industry – is sufficient to mislead the average reader into thinking the proposed “option” is going to be available to everyone. The appearance of all three features in a single question virtually guarantees that outcome.

The September 12-18 Kaiser Tracking Poll illustrates this method of misleading readers. The poll asked respondents if they favored or opposed: “Creating a government-administered public health insurance option similar to Medicare to compete with private health insurance plans.” The average reader could be expected to infer from this question that all non-elderly Americans would have the choice of enrolling with the “option.”

Sometimes polls used only two of the three deceptive phrases. For example, the question posed by the June 23-29 Quinnipiac University Poll asked, “Some people say that giving people the option of being covered by a government insurance plan will keep private insurance companies honest. Do you agree or disagree?” Here, two features – saying “people” will have access to an “option,” and referring without qualification to the entire insurance industry – are misleading.

Only one poll – the one conducted by ABC and the Washington Post between September 10 and 12 – bothered to ask how respondents felt about the “option” actually being proposed by the Senate HELP Committee bill and HR 3200. And this question came only after the poll had asked a question implying the “option” might be available to everyone. Here are the two questions:

“Would you support or oppose having the government create a new health insurance plan to compete with private health insurance plans?”
Support: 55%
Unsure: 3%

If oppose/unsure: “What if this government-sponsored plan was available only to people who cannot get health insurance from a private insurer? In that case, would you support or oppose it?”
Support: 21%
Oppose: 24%

The fact that the authors of this poll felt it necessary to ask a separate question about a version of the “option” limited to the uninsured indicates they understood that their first question implied an “option” available to all. The first question doesn’t say explicitly that the “option” will be universally available, but it conveys that impression with just one of the three deceptive features commonly used by the polls examined here. It doesn’t use the word “option,” and it doesn’t compare the “option” to Medicare; it merely depicts the “option” as competing with the entire insurance industry. In my opinion, that device alone is sufficient to connote universality. By asking the follow-up question, the authors of this poll indicate they agree with me.

What can we learn from these polls?

Of the 23 polls that posed a question about the “option,” only the ABC/Washington Post poll I just discussed could be said to be accurate, and even that is a questionable statement. To put this the other way around, at least 22 of the 23 polls I examined failed to convey accurate information about the actual “option” under consideration by Congress. It is impossible, therefore, to reach any conclusions about how the public feels about that “option.” Because 21 of the 22 polls that conveyed some information about the “option” asked questions exclusively about a version of the “option” that resembles the one Jacob Hacker originally proposed, we can only draw conclusions about that version. The one tentative conclusion we can draw is that the public appears to support the original Hacker version of the “option” – the large, Medicare-like public program. We must consider this conclusion tentative because the campaign for the “option” has been so deceptive and vague, and because the polls made no effort to undo the deception or compensate for the vagueness.

With one exception, the polls that sought to measure public support for the “option” found majority support. The one exception was a poll conducted for Fox News between July 21 and 22. That poll found 44 percent in support of the “option” and 48 percent opposed. An examination of the wording of that poll does not indicate why Fox came up with such a low estimate of public support. Among the other polls, support ranged from 52 to 76 percent. My eyeball analysis of these results suggests support did not decline over the summer as criticism of the “option” and the Democrats’ plans escalated.

It is impossible to say with any confidence whether the support reported by these polls is strong or weak. I found only one poll that offered useful information on that issue. The poll – the ABC/Washington Post poll quoted above – found that the public’s support for the “option” (the original version, not the actual one) is somewhat wide but very shallow. After posing the question I quoted above and finding a 55-percent support level, the poll asked:

“Say health care reform does NOT include the option of a government-sponsored health plan. In that case would you support or oppose the rest of the proposed changes to the health care system being developed by Congress and the Obama administration?”

Fifty percent said yes to this question. In other words, only 5 percent of respondents felt the “option” was essential to effective reform. However, we should take into consideration how vague and inept the bait-and-switch campaign for the “option” has been. A more skillful campaign for a huge public program, as opposed to the know-nothing, deceptive campaign waged on behalf of the mouse version of the “option,” might have created more enthusiasm for the “option.”

Reporters and pollsters need to do their homework

In previous essays about the “option” I have called on the leaders of the “option” movement to notify their followers and the public that Congress is not talking about the original Hacker version of the “option.” That plea has fallen on deaf ears. I will not repeat it here.

I would, however, like to urge polling firms, reporters and bloggers to report on the deception being practiced by the leadership of the “option” movement or, at minimum, to stop participating in that deception by repeating the myth that “poll after poll” shows Americans want the “public option” being discussed in Congress. If pollsters, reporters and bloggers had refused to go along with the “option” campaign’s bait-and-switch tactic, the tactic would not have worked. But they did go along with it, and the tactic appears to be working. The vast majority of Americans, even Americans who attempt to stay abreast of the health care reform issue, appear to be under the impression that the “option” will be available to the entire non-elderly population (or at least to that portion without access to a non-Medicare government program such as Medicaid).

This illusion cannot, of course, last forever. But the longer it goes on, the worse the backlash will be when Americans are finally disabused of the illusion. If they are “falling out of the bleachers” now (to quote Sen. Wyden) when they learn how few Americans will be able to participate in the “option, how are they going to feel when Republicans and the lazy media start telling them, say, next January? Americans need accurate information about the actual “option” under consideration in Congress, and they need it now. If Health Care for America Now and other “option” advocates won’t provide that information, pollsters, reporters, and bloggers should. But with woefully few exceptions, pollsters, reporters and bloggers are selling the notion that the “option” will be universally available.

Pollsters, reporters and bloggers are also selling the unproven claim that the public supports the “option” described in the Democrats’ legislation. Pollster Celinda Lake, who actively participated in the bait-and-switch campaign for the “option,” was quoted recently saying, “Poll after poll shows that large majorities of Americans support reform that offers a choice of a public health insurance plan or private insurance.” To take another example, in an interview on October 15 Tamryn Hall of MSNBC asked Sen. Mary Landrieu (D-LA), “Do you believe in the polling data that says that the American people want a public option?”

Lake’s statement and Hall’s question were not demonstrably false (it’s possible a majority of Americans support the mousey version of the “option” called for in the Democrats’ legislation), but they sure were misleading. The fact is we simply don’t know what the public thinks of the moribund little “option” proposed by the Democrats. Perhaps someday we will. Perhaps someday pollsters will get around to asking accurate questions about the real “option” – questions that do not suggest the “option” will be available to all and do not suggest that it will resemble Medicare.

Kip Sullivan, JD is a member of the Steering Committee of the Minnesota Chapter of Physicians for a National Health Program.

* An earlier version of this post erroneously stated four of 22 polls explicitly stated that the “public option” would be available to everyone.

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Dartmouth variations – looking back and looking forward

Posted by on Friday, Oct 16, 2009

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure

By Michael K. Ong, Carol M. Mangione, Patrick S. Romano, Qiong Zhou, Andrew D. Auerbach, Alein Chun, Bruce Davidson, Theodore G. Ganiats, Sheldon Greenfield, Michael A. Gropper, Shaista Malik, J. Thomas Rosenthal and José J. Escarce
Circulation – Journal of the American Heart Association
October 13, 2009

Background: Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.

Methods and Results: (Warning: This section is technical and you may want to skip it for now.) A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission (“Looking Forward”). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death (“Looking Back”). “Looking Forward” risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were 0.68 between mortality and hospital days, and 0.93 between mortality and indexed total direct costs. “Looking Back” risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.

Conclusions: California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.


* Substantial variation has been documented among hospitals in the resources used to care for elderly Medicare beneficiaries with chronic illnesses during the last 6 months of life.

* By only including individuals who have died in the analyses, researchers cannot identify differences on health outcomes such as survival.


* This study found variation among California teaching hospitals in survival for patients hospitalized with heart failure. This variation would have been overlooked by a study that only examined heart failure patients who died.

* When analyzing all patients hospitalized for heart failure, California teaching hospitals that used more resources had lower mortality rates.

* When analyzing all patients hospitalized for heart failure, the variation in resource use among California teaching hospitals was 27% to 44% less than the variation observed when analyzing only heart failure patients who died.


As the nation attempts to identify ways of slowing the excessive growth in our health care costs, it is only natural that we would look at the great variability in health care spending that does not seem to correlate with health care outcomes. John Wennberg and his colleagues, in producing the Dartmouth Atlas, have confirmed that these variations are very real, though more recent refinements have demonstrated that the differences are not quite as great when corrected for other factors.

A prior study of California hospitals showed that these differences were not limited to those areas for which there seems to be an easier explanation (private hospitals with a liberal supply of high-tech services and professionals treating wealthier patients versus under-budgeted safety-net institutions treating low-income patients), but these Dartmouth differences were also noted between the various University of California teaching hospitals, which have similar funding, staffing and equipment.

This new study looked closer at the differences between the University of California teaching hospitals (including one private teaching hospital affiliated with UCLA). The authors showed that looking back for six months at patients who had died of heart failure did confirm the differences, although not as great since more variables were considered. Higher spending did not improve outcomes for the obvious reason that patients were selected for study on the basis of a common outcome – death.

The important contribution of this study is that they selected the same disorder as used in the death study – congestive heart failure – and looked forward for six months for the outcome of survival or death. This study showed that the teaching hospitals using more resources (spending more money) had a lower incidence of death.

Okay. Now, what care are we going to refuse to fund? Just looking at congestive heart failure alone, it is going to be very difficult to sort out the details to determine which interventions are of value and which are not. Now think of the task of sorting out these differences for all other serious disorders.

So how do we select out those services that should be eliminated from coverage? Legislators and bureaucrats certainly understand that they are not up to the task, so what do they recommend? They are suggesting that we lower spending by paying only for efficient care (i.e., by paying less money), by bundling payments and using accountable care organizations. Third party payers would distribute the funds while health care professionals would micromanage the use of those funds.

Think of the logistical nightmare of contracting with all the services and facilities that would be required in an accountable care organization. Even just informally gathering these services together to accept a bundled payment would entail similar logistical barriers. But then think of the internal conflicts that would occur when it comes time to decide how to divide up the spoils. The micromanagement within these entities would not be based on projected optimal outcomes, but they would be based on pecuniary interests.

If high-quality teaching institutions within the same university system are having difficulties fine tuning health care, how could we ever expect all facilities throughout the nation to adhere to the highest standards when they aren’t even understood?

Although we can continue to study the differences and educate professionals on better practices, we can’t really look to the Dartmouth variations as a quick source of cost savings to finance our other health care needs.

But there is one quick measure that would provide a great start for achieving a higher-value health care system. Get rid of the private insurers and establish an improved Medicare system that would include all of us. That would save about $4 trillion in the next ten years that could be used on actual health care, without increasing our national budget deficit. With a single financin

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