California and New York lessons for Medicaid expansion under PPACA

Posted by on Tuesday, Jan 4, 2011

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.

Cuomo Targeting Medicaid Spending

By Jacob Gershman
The Wall Street Journal
January 4, 2011

Gov. Andrew Cuomo is aiming to reduce the state’s Medicaid spending by billions of dollars, exceeding the size of cuts to the program proposed in past years, according to individuals with knowledge of his budget.

The Cuomo administration is considering a cut of about $2.1 billion out of the state’s projected spending on Medicaid in the upcoming fiscal year. With federal matching funds, the cut comes to more than $4 billion.


Brown to propose broad list of budget cuts

By Kevin Yamamura
The Sacramento Bee
January 3, 2011

(Gov. Jerry Brown) will propose Medi-Cal (Medicaid) savings by requiring patients to provide co-payments for services, limiting doctor visits and reducing rates paid to health providers. In Healthy Families (CHIP), which provides subsidized care for low-income children, he wants participants to pay more in premiums and co-payments while eliminating vision care.

“These would be shocking cuts if we hadn’t seen them before, but we have seen them before,” said Anthony Wright, executive director of Health Access California. “This is what’s left to cut outside of the wholesale dismantling of core programs. These are bad cuts that will impact millions of Californians.”

A substantial increase in eligibility qualification for the Medicaid program is a crucial measure in the Patient Protection and Affordable Care Act (PPACA), designed to decrease the numbers of Americans without insurance coverage. Now the newly-elected Democratic governors of the two most populous states in the nation intend to sharply reduce funding of their Medicaid programs. What does this say about the wisdom of the PPACA policy of using Medicaid to expand coverage?

Gov. Brown’s proposal to impose financial penalties for accessing care, placing caps on doctor visits, and further slashing payments in this already critically underfunded program can only be disastrous for the low-income patients enrolled.

Once again, this is not change we can believe in. We desperately need an improved Medicare that covers everyone.

Drug firms providing kickbacks for co-pays and coinsurance

Posted by on Monday, Jan 3, 2011

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.

Coupons for Patients, but Higher Bills for Insurers

By Andrew Pollack
The New York Times
January 1, 2011

With drug prices rising and many people out of work, pharmaceutical companies are increasingly helping patients with their co-payments.

Drug companies say the plans help some patients afford medicines that they otherwise could not.

But health insurers and some consumer groups say that in many cases, the coupons are just marketing gimmicks that are leading to an overall increase in health care costs. That is because they circumvent the system of higher co-pays on costlier drugs that insurers use to encourage consumers to use less expensive products.

Any shift to brand-name drugs can have a big impact on health care costs.

At District Council 37, a union representing public employees in New York City, 59 percent of claims for statins in the year ended in June 2009 were for brand-name products that cost the plan $17.3 million. The other 41 percent of claims were for generic statins, which cost only $179,000. A year ago, the health plan eliminated the co-pay on generic statins to encourage more use of them.

For very expensive drugs, co-pay assistance is almost de rigueur, because in some cases co-payments can be up to 20 percent of the price of the drug. Novartis’s new pill for multiple sclerosis, Gilenya, costs $48,000 a year, compared with $30,000 to $40,000 for rival drugs, which are injected. Novartis is offering to cover the entire co-pay, up to $800 a month, which is 20 percent of the drug’s monthly cost.

Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years, according to a recent report from the securities firm Jefferies & Company. To cushion patients, the company recently increased its co-pay assistance to as much as $1,200 a month.

Drug companies cannot offer co-payment assistance for patients in federal programs like Medicare because such offers are considered an inducement to use a drug and in violation of anti-kickback laws. Some companies have responded by contributing to, or even helping to set up, charitable foundations that can provide co-payment assistance legally.

Executives at insurers and pharmacy benefit management companies say they would like to counter the cards and coupons but are not sure exactly how to do so. One problem is that the information they receive from pharmacies does not specify whether the co-pay was made by the patient or by the drug company.

“The payer doesn’t know, and the P.B.M. doesn’t know,” said F. Everett Neville, chief trade relations officer at Express Scripts, a pharmacy benefits manager. “We have no ability to stop it and no ability to prohibit it.”

Should a health care system be designed to ensure that patients receive appropriate medications that they should have to relieve symptoms or cure disease? Of course. Yet co-payments (a dollar amount) and coinsurance (a percentage of the cost) impose on the patient financial barriers to the medications – barriers which frequently are not surmounted, and thereby may result in impaired health outcomes.

With our fragmented system of financing health care those seeking greater profits will always find another way to achieve their goals. In this instance, the pharmaceutical manufacturers have found a way to reduce or eliminate these financial barriers to their products.

In providing cost-sharing assistance to the patient, the manufacturers are not specifically removing barriers to the most appropriate products, but rather are removing barriers to their most profitable products, irrespective of whether or not they are the best choice. Since these are more expensive products, that increases the drug costs of the private insurers. Those of us paying premiums to private insurers that cover drugs are paying for these excess costs.

These practices do not require collusion with the physicians and pharmacists since their marketing practices are effective in creating a demand for their products regardless of the appropriateness.

Note that these pharmaceutical industry subsidies of co-payments and coinsurance are illegal in federal programs such as Medicare because they are the equivalent of kickbacks. If we had a Medicare program that covered everyone and eliminated the private intermediaries such as the insurers and pharmacy benefit managers, then these kickbacks wouldn’t exist. Drugs would be prescribed based strictly on appropriateness, and would be priced to provide fair profits for the pharmaceutical firms and fair costs for Medicare.

Republican rules threaten health care

Posted by on Thursday, Dec 30, 2010

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.

Deficit Hypocrisy

The New York Times
December 29, 2010

On Dec. 22, just before they left town for the holidays, House Republican leaders released new budget rules that they intend to adopt when they assume the majority in January and will set the stage for even more budget-busting tax cuts.

The new Republican rules will gut pay-as-you-go because they require offsets only for entitlement increases, not for tax cuts.

It gets worse. The new rules mandate that entitlement-spending increases be offset by spending cuts only — and actually bar the House from raising taxes to pay for such spending.

Even worse, they direct the leader of the House Budget Committee to ignore several costs when computing the budget impact of future actions.

For example, the cost to make the Bush-era tax cuts permanent would be ignored, as would the fiscal effects of repealing the health reform law. At the same time, the new rules bar the renewal of aid for low-income working families — extended temporarily in the recent tax-cut deal — unless it is fully paid for.

Rules draft (33 pages):

Although long, the new Republican rules for the House of Representatives read somewhat like those jokes that are circulated around the Internet. When the fact sinks in that this is no joke but that these rules are very real, the inhumanity implicit in these new rules induces a feeling of despair.

Think of what these rules do for public funding of health care under the Patient Protection and Affordable Care Act. Because health insurance is too expensive and out-of-pocket costs are also unaffordable, government subsidies are necessary, but those called for in the act are inadequate. Many people who will need health care will face financial hardship unless the subsidies are increased.

Under the Republican rules, increases in these subsidies cannot be paid for by increasing taxes. Only reductions in other programs can be used. This is not unlike the prohibited act of cannibalizing one military vehicle to get another one up and running, when both vehicles are essential. Just as we have a responsibility to pay our taxes, our government has a responsibility to ensure that appropriate publicly-financed services will be there when needed, whether it’s maintaining our military vehicles, supporting transportation services in major snowstorms, or ensuring that everyone always has access to affordable health care.

Although the Republicans display a decidedly uncaring attitude toward the financing of important public services shared by most of us, they have an almost sacred devotion to protecting higher-income individuals from the need to pay their equitable share of the taxes to fund those services.

Any increases in spending for the public good must be offset by reductions in other services that would then no longer be available for the public good. Yet, under the new Republican rules, any tax reductions which would accrue primarily to the benefit of the wealthy do not have to be offset at all. Instead, those deficits are added to our debt burden and the debt burden passed on to our progeny.

Is the tax burden in the United States so great that we must sacrifice our public services while burdening ourselves with more debt simply to provide tax relief for the wealthy? The following chart provides that answer. The United States has one of the lowest tax burdens of all nations. The Republicans are catering to the rich at a great cost to the rest of us. What is really tragic is that it seems that, rather than electing representatives who care, the American voters would rather attend tea parties.

If the following OECD chart was not transmitted in this message, it can be accessed by scanning down to Chart A at this link:,3343,en_2649_37427_46661795_1_1_1_3742…

Total tax ratio as percentage of GDP, 2008

Private insurers depending on Medicaid for growth

Posted by on Wednesday, Dec 29, 2010

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.

Insurers Bid for State Medicaid Plans

By Avery Johnson
The Wall Street Journal
December 29, 2010

Health insurers are preparing to capitalize on $40 billion of new opportunities to run privately managed Medicaid plans for the states, which would position insurers to benefit from the health overhaul’s expansion of Medicaid in 2014.

Medicaid is one of health insurers’ few bright spots, as their margins are pressed by regulatory crackdowns on premiums in their traditional policies. Gail Boudreaux, UnitedHealth’s executive vice president, told investors last month that: “The Medicaid space is a significant long-term growth opportunity for us. It’s a big market that’s getting even bigger.”

Budget crises mean cash-strapped states are more willing than ever to outsource their programs to private companies.

When you hear that the nation’s largest (in revenue) investor-owned insurer is looking at taxpayer-financed Medicaid as “a significant long-term growth opportunity,” be afraid. Be very afraid.

Reagan and Churchill – contrasting views on health care

Posted by on Tuesday, Dec 28, 2010

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.

Two Views of Health Law

Letters, The New York Times
December 27, 2010

To the Editor:

Re “In Health Law, Old Arguments Get New Airing,” by David Leonhardt (Economic Scene, front page, Dec. 15):

It is interesting to compare Ronald Reagan’s argument opposing Medicare as “socialized medicine,” a program that would take away the freedom of “our children and our children’s children,” with the words of one of his heroes.

In 1944 Winston Churchill, while still prime minister, said that “our policy is to create a national health service in order to ensure that everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

Humphrey Taylor
New York, Dec. 15, 2010

The writer is chairman of the Harris Poll.

“In Health Law, Old Arguments Get New Airing,” by David Leonhardt:


Actually, Reagan Wasn’t So Proud of That 1965 Medicare Speech

By David Weigel
The Washington Independent
August 21, 2009

In the last month, there’s been a rediscovery of Ronald Reagan’s 1965 recording “Ronald Reagan Speaks Out Against Socialized Medicine.” Something that’s largely been forgotten, though, was that a much more famous Reagan quote — his “There you go again” dismissal of President Jimmy Carter in the 1980 presidential debates–came when Reagan denied that he really meant this, or that he was “opposing the principle of providing care for” seniors in 1965.

Winston Churchill represented the view of most conservative politicians in recent history when he said that “everybody in the country irrespective of means, age, sex or occupation shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

Even Ronald Reagan tried to erase his personal history of opposing Medicare by stating during the debate with President Carter, “I happened to favor the other piece of legislation and thought that it would be better for the senior citizens and provide better care than the one that was finally passed.”

So what has happened? Why are conservative politicians in the United States implicitly paying homage to the Chicago school of economics when their policies result in tens of millions of Americans being denied equal opportunities to benefit from the best and most up-to-date medical services that Winston Churchill spoke of? Does the faith in the abstraction of free market ideology really trump the actual health and welfare of the citizenry?

It would be too much of a stretch to classify this as a folie en masse. However the feigned obliviousness toward the unmet needs of fellow citizens can hardly be interpreted as anything other than heartless neglect driven by greed.

The conservatives and their moderate co-conspirators have updated Russell Long’s famous quotation: Don’t tax you, don’t tax me, and above all don’t even consider taxing that rich man behind the tree even if it means destroying social justice and common decency along with it.

Only 8,000 enroll in health plan for preexisting conditions

Posted by on Monday, Dec 27, 2010

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.

Only 8,000 enroll in health plan for preexisting conditions

By Geri Aston
American Medical News
December 27, 2010

As of Nov. 1, only 8,011 people were enrolled in the Pre-Existing Condition Insurance Plan, numbers from the Dept. of Health and Human Services show.

People who have been denied coverage by private insurers because of a preexisting condition and who have been uninsured for at least six months are eligible to participate in PCIP. The idea is to give patients who have no access to private coverage because of their condition a way to get insurance while they wait for the state-based health insurance exchanges to launch in 2014.

Almost 6 million Americans are potentially eligible for the program, which runs through 2013.

One of the highly touted transitional programs of the Patient Protection and Affordable Care Act is the temporary high risk health insurance pool program designed to provide health insurance for individuals with preexisting conditions. Until the state insurance exchanges are in operation in 2014, this program provides a source of insurance coverage for eligible individuals who have been rejected by private insurers because of preexisting conditions.

How successful has the program been so far? After four months of this three and one-half year program, 99.9 percent of eligible individuals have not yet been enrolled. Only 8,011 out of about 6,000,000 eligible have.

Several explanations have been advanced as to why participation is so low, but they are trivial compared to the most fundamental reason. Our fragmented, dysfunctional health financing system based on private insurance plans will never be capable of bringing everyone in and making the premiums and out-of-pocket spending affordable. As this program demonstrates, trying to apply patches to a rickety financing infrastructure will never be adequate to provide health security for everyone.

We need to dump the crumbling financing infrastructure based on the obsolete model of private plans and replace it with the sturdy structure of an improved Medicare that covers everyone.

George Annas on the constitutionality of Medicare

Posted by on Friday, Dec 24, 2010

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.

Can Congress Make You Buy Broccoli? And Why That’s a Hard Question

By Wendy K. Mariner, J.D., M.P.H., George J. Annas, J.D., M.P.H. (corresponding author), and Leonard H. Glantz, J.D. (From the Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health)
The New England Journal of Medicine
December 22, 2010

The continuing uncertainty over the constitutionality of the Affordable Care Act (ACA), illustrated by conflicting trial court rulings and scholarly commentaries, raises the question of why this constitutional question is so hard to answer. There are at least four reasons.

(The four reasons are discussed in the article.)

A much easier question to answer is why we’re facing this constitutional turmoil. Why, for example, is there no constitutional fuss over Medicare, Medicaid, or veterans’ health care? These programs raise no constitutional issue because they are government benefit programs funded by taxes, and the Constitution explicitly authorizes Congress to tax and spend for the general welfare. Had the ACA expanded Medicare eligibility to everyone, or created a new government health benefit program, there would be no constitutional issue. The constitutional controversy is the direct result of the insistence by conservative legislators that any health insurance reform must preserve the private insurance industry, which necessitated the addition of the individual mandate that is now being fought in the courts by similarly conservative forces.

Although these views on the constitutionality of Medicare have been discussed by others, including PNHP’s leadership, this NEJM article is of prime importance in the continuing health reform debate because it represents the views of respected ethicist George Annas and his colleagues.

The editor’s decision to use broccoli in the title stems from the comments of Florida’s Judge Vinson who questioned whether Congress could require everyone to buy broccoli. Cute. But that distracts from the fundamental issue that should have been selected for inclusion in the title.

Our founding fathers drafted a Constitution that recognizes the primacy of government in the establishment of benefit programs, and explicitly authorizes Congress to tax and spend for the general welfare. That does not extend to taxing and spending for the welfare of the private insurance industry, especially when that is the most expensive and least efficient model of reform – one that leaves so many out, and creates financial hardship for many more.

Is anyone else ready for a national movement to petition Congress to grant us our right to a government health benefit program for everyone – an improved Medicare for all?

Is HHS serious about controlling insurance premiums?

Posted by on Tuesday, Dec 21, 2010

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.

Rate Increase Disclosure and Review

Department of Health and Human Services
Filed December 21, 2010

This document contains proposed regulations implementing the rules for health insurance issuers regarding the disclosure and review of unreasonable premium increases under section 2794 of the Public Health Service Act. The proposed rule would establish a rate review program to ensure that all rate increases that meet or exceed an established threshold are reviewed by a State or HHS to determine whether the rate increases are unreasonable.

Under this approach, if a proposed rate increase equals or exceeds a defined threshold, it would be considered “subject to review.” The review process would then determine if the increase is, in fact, unreasonable.

Rates above the threshold would not be deemed or otherwise determined to be unreasonable in advance of this review. As discussed below, for rate increases filed in a State on or after July 1, 2011, or effective on or after July 1, 2011 in a State that does not require a rate increase to be filed, the threshold for whether rates are subject to review would be whether the average weighted increase in the rate filing, alone or in combination with prior increases in the preceding 12 month period, is 10 percent or more.

In establishing the 10 percent threshold for determining which rates are subject to review, HHS has balanced the wide range of available data on rate and medical trend increases. Our review of the limited data available suggests that the majority of increases in the individual market exceeded 10 percent each year for the past 3 years.

These yearly increases significantly exceed some national measures of medical cost inflation, such as the medical component of the Consumer Price Index, whose inflation has typically ranged from 3.7 percent to 4.4 percent. The Centers for Medicare and Medicaid Services’ National Health Expenditures (NHE) data is another measure of health care cost trends based on overall national health care spending. The five most recent years of available NHE data suggest that overall health care expenditures have increased at an annual rate between 4.4 percent to 6.9 percent. Some commenters suggested using these indices as thresholds for a review of rate increases. Another national index, the Standard & Poor’s Healthcare Economic Commercial Index, also measures insurance rate trends.  The S & P Index measures trends in provider claims costs, which encompasses both unit cost and utilization changes; the trend in that index from September 2009 to September 2010 was 8.5 percent.

The 10 percent threshold established in this regulation exceeds these major indices and in doing so balances industry concerns that any threshold would be over-inclusive with the competing concern that it would subject to review too few rates that may be unreasonable. As we discuss below, when better and more specific data on trends in insurance rates in individual States can be collected, State-specific thresholds would be established.

This approach does not provide for the review of every proposed rate increase, no matter how small, to determine whether it is unreasonable. We recognize that the choice of any threshold makes it inevitable that unreasonable rate increases below the threshold will not be reviewed, and that a proposed increase of less than 10 percent would be unreasonable if the actuarial assumptions underlying the increase were invalid or unreasonable. In proposing this approach, HHS also has taken into consideration the fact that many States, as discussed below, conduct a rate review process for all rate increases without regard to the magnitude of the increase. We expect the number of States conducting such reviews to increase in light of additional resources provided under the rate review grants and passage of State legislation. Therefore, as a practical matter, in a growing number of States, there is even less likelihood that an unreasonable increase below the threshold would be implemented.

In establishing an initial 10 percent threshold for whether a rate increase is subject to review, as discussed below, HHS recognizes that rates, underlying costs, and health care trends vary from State to State.

As discussed below, the State-specific threshold would be based on the same analysis used to develop the initial 10 percent threshold, but would be based on data from the specific State, rather than the national data we analyzed in selecting the proposed 10 percent figure.

Applying this regulation to the large group market would result in a process that is not closely aligned with most State processes upon which the regulation is modeled. In addition, many issuers are not accustomed to submitting proposed rate increases for review in this market. Finally, purchasers in the large group market have greater leverage than those in the individual and small group markets, and therefore may be better able to avoid imposition of unreasonable rate increases. For these reasons, under this proposed regulation, rates in the large group market would not be subject to the rate review process we are proposing.

Proposed regulation (136 pages):

Besides being sure that everyone is covered by a comprehensive system of financing health care, the other important goal of reform was to slow down the intolerable increases in health care costs. The token cost containment measures included in the legislation will likely have little impact, so attention was given to the false proxy of health care costs: the increases in insurance premiums. So how effective will the proposed regulations be in controlling the inexorable rise in insurance premiums?

To begin with, the regulations cover only the individual market, leaving out the much larger market of employer-sponsored health plans. Since the increases in health care costs have placed an undue burden on employers, and indirectly on their employees, this is a serious omission.

As far as setting a threshold for selecting the level of unreasonable premium increases which would be reviewed, Health and Human Services (HHS) has decided that plans with less than 10 percent premium increases would not be reviewed. That is a level well in excess of measures of medical cost inflation. Imagine compounded premium increases of 9.99 percent per year on top of premiums that are already unaffordable. It is true that the 10 percent threshold may be revised, but the change is to be “based on the same analysis used to develop the initial 10 percent threshold.”

Thus, in assuaging the insurance industry’s fears that “any threshold would be over-inclusive,” HHS has made a decision to allow the private insurance industry to keep jacking up its premium rates at unreasonable and intolerable levels. That is no surprise considering the inadequacy of the measures theoretically designed to control the health care spending that the insurers would have to cover.

We can go back and do it right. We can create a beneficent public monopsony that covers everyone with a financing system that slows health care inflation to a tolerable level: an improved Medicare for all. That has to be better than a 9.9 percent compounded increase in premiums that we would be mandated to pay to the perverse, intrusive private insurance industry.

McKinsey: 30 to 40 million could remain uninsured

Posted by on Monday, Dec 20, 2010

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.

Checking In With Dr. Robert Kocher On Who Might Stay Uninsured In Spite Of The Individual Mandate

By Amita Parashar
Kaiser Health News
December 20, 2010

McKinsey and Co., an international consulting company, estimates the number of people residually uninsured will be as high as 40 million in 2016. Dr. Robert Kocher, director of the firm’s Center for U.S. Health System Reform and a former special assistant to President Barack Obama on health care, recently spoke with Kaiser Health News’ Amita Parashar about the center’s estimates and who might not get insured as the health law takes effect.

Q. How did you come up with the figure that 30 million to 40 million people might remain uninsured after the individual mandate kicks in?

A. We built a simulation that allows us to model each county in the country. The model looks at businesses and individuals, coverage flows and changes over time. The model factors in health conditions, incomes, age and can allow one to make forecasts. … It is difficult to predict how big the residually uninsured market will be since it depends on many factors — how effective the individual mandate proves to be, how well auto-enrollment works [a provision of the law that will require large employers to enroll employees in a health plan, unless workers choose to opt-out], and how effectively exchanges and Medicaid programs work to enroll people. Depending on what you believe about these factors leads you to a large range for how many people will be residually uninsured. In some scenarios, that pool may be as large as 30 to 40 million people.

Q. Who are the residually uninsured?

A. There will always be a residual pool of uninsured that includes the following populations: undocumented [foreigners], people between jobs, those who may lose coverage from either changes in income [or from] rolling off of Medicaid. Also, the [people whose employer-based coverage] was dropped but who haven’t yet purchased insurance; those eligible and not enrolled in Medicaid; and those [who have not enrolled in insurance] by choice.

Q. Who do you think will choose to pay the penalty instead of getting insurance?

A. I’m not sure how big that population will be, but I think it’s conceivable that there will be people who are offered employer-sponsored insurance and choose not to take it when they don’t have an alternative and are above the income levels that would allow them to get other options. Naturally, there is going to be turnover, too, as people change jobs or move across state lines. There will be gaps in coverage that will hopefully be easier to remedy than they are today. But there will certainly be people who are in transit in the system, too. And there are some people that ideologically may choose not to get coverage, or to self-insure. While I think that’s going to be a relatively small population, I expect that there will be some that make that choice.

McKinsey and Co. estimates that as many as 30 to 40 million people will still be uninsured after the new health care law goes into affect. Telling people to do something they can’t do – buying subsidized health insurance that they still can’t pay for – will never succeed as a policy to eliminate the uninsured.

Enrollment needs to be automatic for everyone, with an automatic, equitable system of funding that makes it affordable for all – progressive taxes. That’s not such a difficult concept. I’ll bet you could easily solve it right now: an improved (fill in the blank) for all.

A spectacle of the health care crisis

Posted by on Friday, Dec 17, 2010

By Ed Weisbart, M.D.

I get overwhelmed when I try to think about the facts that there are over 50 million Americans without healthcare insurance and millions more with grossly inadequate insurance. I’m just as devastated to know that this kills 46,000 of us every year. I personally find it almost impossible to fully grasp the scale of these numbers, to fully understand the human impact of this ongoing disaster. Even welcoming uninsured patients into my medical practice and seeing them on a daily basis still masks the enormity of the problem to me.

I recently had the opportunity to get more of a sense of the human scale by volunteering at one-day massive mobile clinics sponsored by the National Association of Free Clinics (NAFC), the non-profit organization that supports the 1,200 brick and mortar free clinics across the country. This is the safety net that catches people who can’t afford even the modest fees  charged in the network of community clinics (FQHCs). About two years ago, NAFC began a campaign to bring greater public awareness to the plight of uninsured Americans by sponsoring these  free clinics across the nation. There have now been nine of these events in cities ranging from New Orleans to Washington DC, serving over 11,000 uninsured patients (well over 1,000 each day!) and connecting them up with local resources. If you are fortunate enough to have one come to your community, please volunteer your time at

I’ve had the opportunity to volunteer at five of these now and am overwhelmed by seeing the pride and dignity people have despite needless pain and suffering. I’ve seen countless people with the same story:  their employer doesn’t offer an affordable benefit, or they lost their job and COBRA ran out, and now they can’t afford the $130+ their physician must charge them for care, so they’ve run out of their hypertension/diabetes/lipid/migraine/asthma/whatever meds and just desperately want someone to write some refills. “Please, can you help me stay alive?” Unbelievable to see people choosing between their rent and their insulin, but it’s happening every day in our modern society.

Last week I saw a mother with her uninsured 25 year-old son. He’d told her a few days earlier that he had been hearing voices telling him to hurt someone. She’d tried calling local psychiatrists but couldn’t get an appointment given his lack of insurance. She was terrified but didn’t know what to do for him. She saw a notice about our upcoming free clinic, brought him in, and we were able to get him in immediately to see a psychiatrist who was also donating his day’s work. I’m still trying not to  imagine what would have happened if NAFC’s clinic weren’t there that day. Universal healthcare would protect all of us, even those who are “insured” today.

I saw a diabetic terrified about a two centimeter abscess on her foot. We were able to drain it, put her on antibiotics, and get her in for aftercare in 48 hours. She’d had the abscess for several weeks, knew it was a potential disaster, but couldn’t afford to go anywhere for care. Another few days and the outcome could have been much more grave.

This is simply not the America I grew up believing in. Over 80% of the people we see at these clinics are employed, but at jobs that don’t provide affordable healthcare benefits. I saw a woman who works full time at the US Dept of Agriculture as a chef, but has no benefits as they consider her a contract worker. She “works” for the government, but not really.  Congress may mandate that federal employees have benefits, but then they permit this sort of out-sourcing travesty to go on under the radar. She really works for our government, but has no healthcare benefits.

I have one word for this situation: unacceptable.

There’s just no justification to continue our current deplorable linkage between employment and healthcare. This disconnect greatly reduces quality, skyrockets costs, and puts us in a compromised global status. But if ever we needed a clear statement of the dangers of this linkage, the 9.8% rate of unemployment makes this argument far more clearly than ever.

My stomach turns at the political games going on in DC when I realize that each and every day of delay towards universal care, my neighbors are suffering and dying. And frankly, it’s only a matter of time before it’s me and my own family. Or yours.

Every day that we don’t succeed at getting improved Medicare for all, we’re all at risk. Even those of us with “insurance.”

Dr. Weisbart is a family physician located in St. Louis, MO.

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