Is the window for reform really open?

Posted by on Wednesday, Sep 10, 2008

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.

Drop in Uninsured Unlikely to Influence Health Care Overhaul, Experts Say

By Neda Semnani
CQ HealthBeat
September 5, 2008

While new government figures show that a greater enrollment in public health programs has helped reduce the number of Americans without health insurance, experts said the data are unlikely to help make the case for expanding those programs as part of broader health care legislation next year.

David S. Johnson, the Census Bureau’s chief of Housing and Household Economics Statistics, which published the new figures, credits public programs like Medicaid and SCHIP for the increase in the insured, a trend experts believe may continue as employer-based coverage falls.

Analysts said the drop in the uninsured rate will have little influence in the broader discussion of health care legislation expected next year when a new president and Congress take office. The economic downturn and other budget priorities make it difficult for health care overhaul–a costly endeavor–to take center stage, they said.

“How much flexibility does the federal government have, given the declining economy and vast array of other problem areas? We have a lot of policy priorities. Health is an important one, but it’s not the only one,” said Joseph Antos, a health care scholar with the American Enterprise Institute, a conservative think tank. “Some kind of reform needs to happen . . . eventually. Gigantic reforms cost money. So ‘eventually’ may not happen in the first year or even in the first ten years of a new administration.”

Mark McClellan, director of the Engelberg Center for Health Care Reform with the non-partisan Brookings Institution, said, “With the fiscal outlook so tight, the challenge will be finding new ways to get costs down and coverage up, while filling gaps in quality.”

Judith Solomon, a senior fellow at the left-leaning Center on Budget and Policy Priorities, said the report examines the period just before the economic downturn and “doesn’t change what is the case for reform, it doesn’t change the case for reauthorizing strong public programs,” said Solomon, who specializes in Medicaid and the State Children’s Health Insurance Program (SCHIP).

The trend of greater enrollment in public health programs may continue in the current economic slowdown, said Karen Davenport, director of health policy with the liberal Center for American Progress. “On the one hand, we’re likely to see a greater insecurity in health coverage; on the other, a further up-tick in public coverage … The report points out just how effective these programs are in catching people when they fall. It shows that the individual market alone doesn’t work.”

http://www.commonwealthfund.org/healthpolicyweek/healthpolicyweek_show.htm?doc_id=704405

All we need to achieve comprehensive health care reform is to elect a new Congress and a new administration, and use the momentum of the first 100 days to push through Congress the voters’ mandate for reform. Right? Hmmm.

If we are going to have new legislation ready by January or February, the specifics of the proposals need to be precisely defined now so that they are ready to be converted into legislative language ASAP.

Is the McCain proposal ready? It would not be too difficult to write legislation that would diminish employer contributions to health plans by eliminating the tax advantages. It also would be fairly easy to allow sale of plans across state borders thereby creating a competitive market of the lowest common denominator of underinsurance plans. Tearing down programs that aren’t working very well and replacing them with programs that are much less effective is certainly not the reform we need.

What about creating a universal market of private plans like the members of Congress have: an FEHBP-like program? To be effective, these plans would have to cover essentially all necessary health care, and include individuals with greater health care needs. Those plans would be very expensive, certainly more than the $12,000 average premium charged for employer-sponsored plans covering healthy employees and their healthy families. Our current business-based private plans would require massive transformation to convert them into private social insurance plans characteristic of some of the European nations. Can you imagine the complexity of the legislation that would be required? Has anyone seen any serious specifics of such an approach that could be converted into legislative language within the first 100 days?

What about allowing the purchase of a Medicare-like option to complement the private insurance market? It wouldn’t be simply a provision to allow a buy-in to the current Medicare program simply because the Medicare risk pool is composed of very high-cost populations (elderly, chronically disabled, and chronic renal disease), and the premiums could never be affordable. Then what would a separate Medicare-like option look like? Good question. How comprehensive would the benefits be? How could cost-sharing be kept at a reasonable level? How much of the premium would the individual be responsible for? Would the balance be paid by the government? Would the private insurers who benefit from favorable selection be required to transfer funds to the public program? Has anyone seen any serious specifics that could be converted into legislative language in the first 100 days?

We do have legislative language for a proposal that actually would work, and it is already in a bill before Congress, with about 90 cosponsors in the House of Representatives: John Conyers’ HR 676. Oh, wait a minute; that’s not feasible, they tell us.

So what do the Democrats have in mind for the first 100 days, should they have control? Easy. They are going to expand the children’s health insurance program – SCHIP – certainly a good thing. They are going to look at the damage done to Medicare by the privatizers, but significant repairs will be too complex to enact right away; they’ll get to that later. Comprehensive reform? Not now; there are too many other important issues. Next year? Well, that’s an election year, so we can’t do it then. But we should be able to get to it possibly before the end of the president’s first term, and certainly by the end of the second.

Window slammed shut!

But don’t anyone start working on these issues now. We have more important decisions to make. Do we support the moral high ground of lipstick on a pit bull, or the moral low ground of lipstick on a pig?

In the face of all of our shameful societal problems, surely someone will come up with this answer to this most pressing problem of the day: the lipstick needs to go on the figurehead of the Swift Boat.

Doctors pressured by the intrusion of private insurers

Posted by on Tuesday, Sep 9, 2008

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.

Survey Reveals that Doctors Feel Pressured by Health Insurers to Alter the Way They Treat Patients

The Medical Society of the State of New York
September 2, 2008

The Medical Society of the State of New York just released survey results, which indicate that health insurer rules often force New York State physicians to alter the way they treat patients — and not necessarily for the benefit of patients. Instead, the rules appear to have been developed to increase insurer profits at the expense of the best health practices and patients’ health.

The survey results indicate: Ninety percent (90%) of the physicians surveyed said that they have had to change the way they treat patients based on restrictions from an insurance company, and 92% said that insurance company incentives and disincentives regarding treatment protocols “may not be in the best interest of the patients.”

Physicians’ most common complaint was that health insurers required them to change prescription medications; 93% of the physicians voiced this complaint. Over three-fourths (78%) said that an insurance carrier has restricted their ability to refer patients to the physicians they believed would best treat their patients’ needs.

A majority (87%) of physicians said that they sometimes feel that they are pressured to prescribe a course of treatment based on cost rather than on what may be best for the patient. Over half (62%) of the physicians surveyed, however, are either somewhat concerned or very concerned that they may be cut out of an insurance network if they do not follow the policies requested by insurance companies.

http://www.mssny.org/mssnyip.cfm?c=i&nm=Insurance_Carrier_Rules

Complete survey results:
http://www.mssny.org/mssnycfm/mssnyeditor/File/2008/In_the_News/Press_Releases/inscarrierrules.pdf

No person disputes the fact that it is wise to use a less expensive generic medication when a newer product on patent is more expensive, has not been shown to be a better therapeutic agent, and has not been in use long enough to identify potential adverse effects that only post-marketing surveys could demonstrate.

A public insurance program would be designed with incentives to provide the best care possible, with secondary incentives to avoid more expensive options that have no advantage over less expensive options. For example, a $100,000 cancer drug that has not been demonstrated to be any more effective than established agents, and which has a 100 percent incidence of toxic side effects, may not be covered by a public program except perhaps as part of an approved research protocol.

This survey once again confirms that private insurers are intrusive in the patient-physician relationship. We know that their interventions are based on business contracts that they have with pharmacy benefit managers and pharmaceutical manufacturers. Their business interests take precedence over the interests of the patients. In some instances, recommended changes may incidentally benefit patients, but they are made only after the insurers first have made a determination that the change will benefit their bottom line.

Moreover, insurers usually dictate which specialists and which hospitals can be used without the patient incurring significant financial penalties. These authorized referrals are based on provider contracts that accrue to the benefit of the insurer without regard to the wishes of the patient and the advice of the physician. In a well designed public program, patients would have choices within the full range of provider options.

Before we adopt reform based on the private insurance model, we should think about what that means. Amongst the great multitude of problems, we would be adopting a system that allows businessmen to intrude between the patient and the physician and take away with them whatever money they can. That doesn’t seem wise when we could have our own public program that is designed to provide the best care for all of us with the resources that we have.

Libertarian supports single payer

Posted by on Friday, Sep 5, 2008

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.

Libertarians face off on issues

By Andy Steinke
wiscnews.com
September 5, 2008 (date accessed)

Third Congressional District Libertarian candidates Ben Olson III and Kevin Barrett faced off in a debate Sunday night aboard Captain Chris Soma’s boat in Wisconsin Dells.

The two are the first Libertarians to face each other in a primary in the state as they seek the seat held by Ron Kind, a Democrat.

The two called the debate to give the public an opportunity to hear their perspectives on the health care system, Social Security, the war in Iraq and more.

Barrett and Olson agreed in principle on many Libertarian ideals, but it appears the main dissenting point in their campaigns will be their view of the nation’s health care system.

While the acknowledged Libertarian viewpoint is to keep the government from accruing more power than it already has, Barrett, 49, said he was in favor of a single payer health care system run by the government. Barrett said he could flip-flop on the issues, however, if he was offered a better alternative.

“I do think that single payer health care is the best solution to our current problem,” Barrett said, “that doesn’t mean that I believe in it philosophically. Actually I would prefer a non-government run health care system.”

Olson, 55, is running against Barrett in what may be the nation’s first Libertarian primary Sept. 9, because he doesn’t support Barrett’s stance on the health care issue and because he wants a “true Libertarian” on the November ballot.

“In regards to health care,” Olson said, “with our country already heading down a path towards bankruptcy, the last thing that I would want to give the government is the power to run our national health care system.” However, Olson failed to give a different solution to the nation’s health care problem.

“There are a lot of problems and I’m not sure that I have the answer,” Olson said. “But I do know that I firmly believe that the government administering health care in this country is not the answer.”

http://www.wiscnews.com/wde/news/302742

Everyone agrees that our health care system is not performing adequately for far too many of us, especially considering how expensive it is. Currently the nation is debating a spectrum of reform proposals to improve the performance of our system, though many proposals would actually compound the deficiencies.

A major confounding problem is that almost all of us do care about the health of our fellow Americans; even most Libertarians do. Though Libertarians support free market solutions that keep the government out of our lives, anyone who studies the health care system understands that reliance on markets alone cannot ever be effective in ensuring that everyone receives the health care that they need.

What is unprecedented about this debate is that one Libertarian has decided that the single payer model is the “best solution to our current problem.” The other Libertarian doesn’t have an answer but believes that the Libertarian anti-government ideology should have precedence over a solution that would work, merely because effective solutions include a role for government.

No serious student of health policy would contend that a free market of competing private health plans would ever be effective in ensuring affordable health care for everyone. Even the current political proposals touting market competition of private plans support a major role of government through large tax subsidies (such as Sen. McCain’s proposals for a $5000 tax credit for family insurance, and for federally-supported high-risk pools). Effective reform is impossible without a major role for government.

At least one Libertarian who distrusts government has looked at the options and has decided that, if his fellow Americans are going to receive the health care that they need, and the government will have to be involved, then we might as well go ahead and chose the option that is the most efficient and most effective: “a single payer health care system run by the government.”

Now that’s a man who cares about the rest of us.

Employers shift to underinsurance

Posted by on Thursday, Sep 4, 2008

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 benefit cost growth predicted to ease slightly in 2009 as employers shift cost

Mercer
September 4, 2008

After three years of double-digit growth in the first half of the decade, annual health benefit cost increases slowed to about 6 percent in 2005 and have stayed there ever since.

Mercer’s complete survey results won’t be released until later in the year, but for the 1,317 employer health plan sponsors that have responded so far, the total cost to renew their current health plans — if they were to make no changes — would grow by nearly 8 percent on average. Small employers (those with 10-499 employees) would see an even higher increase, of about 10 percent. However, the majority of respondents say they will take action to lower their actual cost increases.

“It’s a relief to see cost growth trending down, even slightly,” said Blaine Bos, a senior Mercer health and benefits consultant based in Minneapolis. “But this is not an unqualified success story. While some employers are holding down cost growth with innovative methods of improving health care quality and efficiency, more typically employers struggling with increases they can’t handle resort to the tried and true method of shifting cost to employees.”

Well over half (59 percent) of employers taking action to reduce their 2009 cost increase will raise deductibles, copayments, coinsurance or employee out-of-pocket spending limits. Employee cost-sharing has risen sharply over the past five years.

http://www.mercer.com/summary.htm?idContent=1319885

Is it good news that employers’ health benefit cost growth is easing slightly? No. If you look at the full picture, it’s terrible news. Health care costs are continuing to increase at an unsustainable rate, but employers are dumping the problem onto the backs of their employees by “the tried and true method of shifting cost to employees.”

Products available in the individual insurance market are no longer providing adequate protection because of increases in deductibles, copayments and coinsurance that trade off affordable premiums for unaffordable access to health care – the very definition of underinsurance.

Employers are now seeking relief from the costs of their health benefit programs by following the lead of the individual market and converting their programs into underinsurance plans.

Reform proposals that would expand competition of plans in the individual market won’t work because most of the plans will be underinsurance products if the premiums are to be competitive. Reform proposals that would expand on employer-sponsored coverage won’t work if that sector becomes saturated with similar underinsurance plans.

If we regulate the markets to prevent the sale of underinsurance products, then the increase in health care costs will continue to make premiums unaffordable for either employers or individuals.

If we really do want everyone to have affordable access to all necessary health care, we have no option but to establish a universal risk pool that is equitably funded, and then to take advantage of our own monopsony to provide us with greater value in our health care purchasing. We are already at that point, and there is nowhere else to turn.

Supreme Court acknowledges insurers' conflict of interest

Posted by on Wednesday, Sep 3, 2008

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.

MetLife V. Glenn: The Court Addresses A Conflict Over Conflicts In ERISA Benefit Administration

by Timothy Stoltzfus Jost
Health Affairs
September 3, 2008

In its June 2008 decision in MetLife v. Glenn, the Supreme Court held that federal courts reviewing claim denials by Employee Retirement Income Security Act (ERISA) employee benefit plan administrators should take into account the fact that plan administrators (insurers or self-insured plans) face a conflict of interest because they pay claims out of their own pockets and arguably stand to profit by denying claims.

As a practical matter, the cost of health benefits to employers and their value to employees are first determined when the employer settles on a benefit, cost-sharing, and premium package for a benefit year. But it is also determined daily as plan administrators (either insurers, self-insured plans, or third-party administrators) make benefit determinations. Although plan coverage is sometimes clear, claims adjudication often involves application of vague terms such as “medically necessary” or “experimental” care to specific situations. Approximately 1.9 million claims are denied by employee benefit plans each year. Each denial potentially decreases the cost of coverage–immediately for self-insured and prospectively for insured employers (which usually pay an experience-rated premium). But denials also potentially decrease the value of coverage to the individual employee.

Claim determinations are ultimately reviewable in the federal courts. The courts’ approach to reviewing these determinations could, therefore, affect the cost of employee benefits. If, on the one hand, courts routinely overturn claim denials, the cost of coverage will increase, not just because plans will lose more appeals, but also because plans will have to litigate more appeals of adverse determinations as members see their chances of appeal improve. Moreover, plans will likely approve more claims initially instead of risking litigation. An increase in the cost of coverage may in turn lead to more employers’ abandoning coverage. On the other hand, if courts routinely defer to plan determinations, upholding most, plans will in all likelihood be more aggressive and confident in denying claims. This could make coverage more affordable but also put employees at risk.

Interpreting an earlier ERISA decision, the Court articulated the question as to what extent courts should defer to the decision of the plan administrator when the administrator faces a conflict of interest because it is essentially paying the claim out of its own pocket and stands to profit if the claim is denied. The Court decided that this conflict must be taken into account as a “factor” in judicial review. This paper analyzes the Court’s decision, the background of the decision, and its potential effect on American health policy.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.5.w430

In this important decision the Court affirmed the obvious. Employer-sponsored plans and their administrators, whether private insurers or self-insured plans, have a conflict of interest when making benefit decisions. Denial of claims benefit the employers and/or insurers, and approval of claims benefit the employees. On this, the justices were in unanimous agreement.

Much of the criticism of private insurance has been directed toward the flagrant, egregious abuses in the individual insurance market. Far more is wasted on administrative services that are designed to weight the conflict of interest heavily in favor of the insurer at the cost of patient-beneficiary. Those who support reform based on private insurance acknowledge that the individual plans would have to be replaced with options that more closely resemble employer-sponsored plans. Is that wise from a health policy perspective?

An important implication of this Supreme Court decision is that costs for employer-sponsored plans will likely increase. Legal costs may rise because of an increase in challenges to claims decisions, which may cause an increase in benefit costs because of employer/insurer decisions to avoid the effort and legal costs of challenging claims for non-beneficial and non-contract services.

Would a single payer national health program eliminate the conflict of interest between the payer of benefits (the government) and the recipient of benefits (the patient)? Of course not. But, as a society, this conflict should work to our benefit.

Our own public program would have a mission to finance all necessary care for all of us. At the same time, it would have a responsibility as stewards of our tax funds to not waste money on non-beneficial services and products. Although disputes would be inevitable in marginal circumstances, the decisions would be based on balancing the needs of the patient with efficiency in the use of our public funds.

Employers would no longer have to face the awkward decisions of saving money by denying care for their employees.

In contrast, private insurers welcome the opportunity to reduce their overhead by denying care to patients. That might be good business, but it’s terrible health policy.

Sen. Kuehl's single payer bill goes to Gov. Schwarzenegger again

Posted by on Tuesday, Sep 2, 2008

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.

Calif. Nurses Laud Passage of Single-Payer, SB 840, Seen as National Model for Guaranteed Healthcare for All

MarketWatch
September 1, 2008

The California Nurses Association/National Nurses Organizing Committee today hailed the California Legislature’s passage of a single-payer, expanded Medicare for all, style bill that would guarantee quality health care for all Californians — and called it a model for the national healthcare reform debate that is sure to emerge in 2009.

SB 840, authored by State Senator Sheila Kuehl, passed its final legislative hurdle with a vote in the State Senate today and is headed to the desk of Gov. Arnold Schwarzenegger who vetoed an earlier version of the bill two years ago.

“But a lot has changed since then, including the further implosion of our healthcare safety net, and the Governor’s own professed support for universal healthcare,” said CNA/NNOC co-president Malinda Markowitz, RN. Nurses will remind Schwarzenegger of that pledge, she said.

http://www.marketwatch.com/news/story/calif-nurses-laud-passage-single-payer/story.aspx?guid=%7B203DC8E2-395B-4836-99E8-2B1C81FFF4F2%7D&dist=hppr

Senate Bill No. 840:
http://info.sen.ca.gov/pub/07-08/bill/sen/sb_0801-0850/sb_840_bill_20080811_amended_asm_v95.pdf

And…

Governor Schwarzenegger’s Health Care Plan

Assembly Bill X1 1, the Health Care Security and Cost Reduction Act:

Requires that all Californians take responsibility for their health coverage (individual mandate).

Guarantees that no Californian will be turned away from buying insurance based on their age or medical history (guarantee issue).

Spreads responsibility across individuals, government, hospitals and employers (shared responsibility).

Makes coverage more affordable for individuals and families through tax credits and subsidies.

Helps keep hospitals and emergency rooms open by increasing Medi-Cal reimbursement rates.

Allows individuals to choose their health coverage and keep their current insurance.

http://www.fixourhealthcare.ca.gov/plan

Two years ago California’s Governor Arnold Schwarzenegger vetoed a prior version of this single payer bill stating, “I must veto SB 840 because I cannot support a government-run health care system.”

He then initiated an intensive effort to create legislation that would provide coverage for all Californians, but crafted to comply with his policy principles listed above. His efforts fell short and resulted in AB X1 1 – legislation that would better be characterized as a take-it-or-leave-it package of incremental reforms. There were many beneficial reforms in the package that have broad support, but there were many other severe deficiencies that provoked considerable opposition. The legislative battle was very painful for all of us who believe that everyone should have affordable access to all necessary health care. The bill essentially died in the Senate Health Committee when supporters could muster only one vote in favor of it.

In passing SB 840 once again, the California State Legislature is giving Gov. Schwarzenegger another opportunity to sign legislation that actually would provide health care for everyone through a model that would use our health care dollars much more efficiently. It will be a test to see if his goal of ensuring health care for all Californians is more important to him than his personal anti-government ideology. Let’s hope that he leaves his intellectual exercises on ideology in his cigar tent as he comes out and signs a bill that benefits the health of the people.

WHO report on inequities that kill

Posted by on Monday, Sep 1, 2008

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.

Closing the Gap in a Generation: Health Equity through Action on the

Social Determinants of Health
World Health Organization
August 28, 2008

Inequities are killing people on a “grand scale” reports WHO’s Commission

“(The) toxic combination of bad policies, economics, and politics is, in large measure responsible for the fact that a majority of people in the world do not enjoy the good health that is biologically possible,” the Commissioners write in Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. “Social injustice is killing people on a grand scale.”

Wealth is not necessarily a determinant

Economic growth is raising incomes in many countries but increasing national wealth alone does not necessarily increase national health. Without equitable distribution of benefits, national growth can even exacerbate inequities.

Wealth alone does not have to determine the health of a nation’s population. Some low-income countries such as Cuba, Costa Rica, China, state of Kerala in India and Sri Lanka have achieved levels of good health despite relatively low national incomes. But, the Commission points out, wealth can be wisely used. Nordic countries, for example, have followed policies that encouraged equality of benefits and services, full employment, gender equity and low levels of social exclusion. This, said the Commission, is an outstanding example of what needs to be done everywhere.

Inequities within countries

In the United States, 886,202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalized.

Universal Health Care

Access to and utilization of health care is vital to good and equitable health. The health-care system is itself a social determinant of health, influenced by and influencing the effect of other social determinants. Gender, education, occupation, income, ethnicity, and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care. Leaders in health care have an important stewardship role across all branches of society to ensure that policies and actions in other sectors improve health equity.

The Commission advocates financing the health-care system through general taxation and/or mandatory universal insurance. Public health-care spending has been found to be redistributive in country after country. The evidence is compellingly in favour of a publicly funded health-care system. In particular, it is vital to minimize out-of-pocket spending on health care. The policy imposition of user fees for health care in low- and middle-income countries has led to an overall reduction in utilization and worsening health outcomes. Upwards of 100 million people are pushed into poverty each year through catastrophic household health costs. This is unacceptable. Health-care systems have better health outcomes when built on Primary Health Care (PHC) — that is, both the PHC model that emphasizes locally appropriate action across the range of social determinants, where prevention and promotion are in balance with investment in curative interventions, and an emphasis on the primary level of care with adequate referral to higher levels of care.

Recommendations

Based on this compelling evidence, the Commission makes three overarching recommendations to tackle the “corrosive effects of inequality of life chances”:

1. Improve daily living conditions, including the circumstances in which people are born, grow, live, work and age.

2. Tackle the inequitable distribution of power, money and resources — the structural drivers of those conditions — globally, nationally and locally.

3. Measure and understand the problem and assess the impact of action.

Press release:
http://www.who.int/mediacentre/news/releases/2008/pr29/en/index.html

Executive Summary (40 pages):
http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf

Full report (256 pages):
http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

On this Labor Day weekend, a time that we celebrate the great contributions of American workers, the release of this report could not be more timely. Hard working Americans are experiencing the adverse consequences of the increasing inequities in the social determinants of health, inequities that really only society is equipped to address. Today, Hurricane Gustav is descending on our Gulf Coast, testing further whether we as a society can join together to meet our challenges, or if instead those affected are simply left on their own.

Please excuse me for a personal moment of introspection. For over ten years I’ve been a full-time volunteer for Physicians for a National Program. I remember well a conversation I had several years ago with David Himmelstein, a cofounder of PNHP. We observed that, while the task of achieving health care for everyone in the United States seemed almost arduous, it was a miniscule problem compared to the needs throughout the world. Ours was such a tiny task in comparison. We didn’t need more money. We merely needed to fix the way we finance health care as an essential first step to begin to address these inequities.

Ten years later one simple number gives us an inkling of the degree of our success. This report shows that over 800,000 African Americans have died prematurely in the United States in the past decade merely because we have failed to address these inequities in the social
determinants of health.

(moment of silence)

Hopefully we’ll do better with Gustav than we did with Katrina, having learned a lesson. But do we really need more lessons on the social determinants of health before we begin to act? Eight hundred thousand is far too many painful lessons for me.

As our health care “system” continues to fall apart in its crisis of access and affordability, new coalitions are popping up all around us, each espousing the urgent need for “ health care reform”. These are some of the bigger, more recent coalitions:

  • Divided We Fail (includes AARP, the Business Round table, and the ServiceEmployees International Union (SEIU); committed to a “search for solutions to health care” – – – by building on private insurance.
  • The National Coalition on Benefits (includes more than 50 of the largest corporations and most powerful lobbying organizations, including private health insurers, the Business Roundtable, and the U. S. Chamber of Commerce; they lobby to keep large employers’ insurance plans exempt from regulation)
  • Health Care for America Now (HCAN), a coalition of many national organizations, including the American Nurses Association, MoveOn.org, and the Progressive Action Network; their common purpose is to promote “an American solution” which assures universal health coverage “through the largest possible risk pools” for affordable health care in an inclusive and accessible system leaving nobody out; it retains choice of a private health plan.
  • Five other organizations — the American Cancer Society’s Cancer Action Network, the American Hospital Association, the Catholic Health Association, Families USA, and the National Federation of Independent Business (NFIB, which represents small business); this group is co-sponsoring the latest Harry and Louise advertising campaign, which expresses concern about cost and access problems, urging that “health care should be at the top of the next president’s agenda. Bring everyone to the table, and make it happen”.

As usual, you can’t tell any of these coalitions’ real agenda by their names. But all of these are committed to preserving the private health insurance industry, and keeping single-payer national health insurance (NHI) off the table. Their message can be very effective by confusing the public, trivializing the debate over policy options, and most importantly, by calling for everyone to come to the table and working toward political compromises which look like reform but are not. Meanwhile, of course, America’s Health Insurance Plans (AHIP), the industry’s trade group, launches its own national propaganda effort Campaign for an American Solution, which argues for “choice” and fails to acknowledge single-payer as an alternative, while the AMA predictably supports continuation of multi-payer financing.

Behind the bland, even patriotic sounding names of these coalitions are conflicts of interest invisible to much of the public. Here are just two examples.

AARP is involved with a lucrative market of supplemental private Medigap plans through United Health; about 60 percent of its revenue (double that from members’ dues) comes from sales of Medigap policies, its membership list, and related activities. AHIP’s conflict of interest, of course, is obvious, but does not restrain its promotional efforts to put itself forward as part of the “reform” process. Since 1999, AHIP has been building its own coalition, the Coalition for Medicare Choices; it includes more than 400,000 senior activists who have lobbied Congress in opposition to cuts in government overpayments to private Medicare plans (already receiving 112 to 119 percent larger payments than traditional Medicare).

In each case, the rhetoric of change obscures the lack of concrete policy changes that could address system problems of health care. Private insurers would like to continue to fragment the market, cherry pick lower-risk healthier people, shift the sick to public financing, avoid regulation, and at the same time receive government subsidies to stay in business.

Alternative Financing Systems and American ValuesBut private insurers are the problem! As pointed out in previous posts, the private insurance industry and open markets have failed, after many incremental attempts over the last 30 years, to resolve system problems. The critical policy alternative before us is: Multi-payer vs Single-payer.

If we frame the alternatives for health care reform on traditional American values, as arguably we should, single-payer wins hands down. The accompanying graphic compares the two financing options by nine values, in each case with unambiguous results favoring single-payer, on the basis of track record and actual experience, not ideology or rhetoric. Health care is not a partisan issue. It is about every American having access to affordable necessary health care, regardless of age, gender, employment, health status, or race. It is about employers being able to compete in a global market with a healthy work force. It is also about pulling together with social solidarity rather than survival of the fittest (those who can pay).

These comparisons between public and private financing are well documented by many studies over the years. But the political process to date keeps allowing well -financed vested interests to change the subject and delay real reform. That happened in 2006 when the Citizen’s Health Care Working Group, created by the Medicare legislation of 2003 and charged with the task of formulating approaches to address health care system problems. Although almost one-half of the more than 800 participants in two years’ of community meetings around the country had supported single-payer NHI as by far the leading option for reform, the resultant document ignored single-payer and instead endorsed a system of private catastrophic coverage with deductibles as high as $30,000, an option not even discussed in community meetings and mostly opposed in online polls.

It is time to recognize distortional politics for what it is, and get on with making our voices heard. Momentum for single-payer NHI is gathering strength, as illustrated by these examples of growing support:

  • There are now 92 sponsors of HR 676 (The United States National Health Insurance Act ) in the House of Congress
  • A majority of Americans have supported publicly-financed NHI for at least 60 years, often as many as two out of three in some surveys; a 2005 national study by the Pew Research Center of the People and the Press found that this support crosses party lines, with 59 percent of social conservatives and 63 percent of pro-government conservatives favoring NHI, even if taxes increase.
  • 59 percent of more than 2,200 U. S. physicians now favor NHI in a survey earlier this year, as do about 60 percent of physicians in Massachusetts and Minnesota ; the American College of Physicians (the second largest medical organization in the country with 125,000 members) has endorsed the single-payer option, as has the American Public Health Association and the California Nurses Association.
  • Organized labor is getting behind single-payer as its employer-based health benefits continue to erode; the AFL-CIO nationally has endorsed the basic principles of single-payer, and a growing number of unions are backing HR 676

The health care crisis challenges our democracy to its core – – – will corporate dollars through deceptively named coalitions continue to trump individual and public will?

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Bernstein and Marmor on "Yes But"

Posted by on Friday, Aug 29, 2008

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.

Medicare-for-All: Why We Should Say Yes, Not “Yes But”

by Merton Bernstein and Theodore Marmor
Health Affairs Blog
August 28, 2008

Many health policy experts regard Medicare-for-All as a model for reform of America’s indisputably troubled and costly medical arrangements. They express admiration for its administrative efficiency and the resulting savings that could pay for extending coverage, perhaps to all. For example, in a June 2008 Health Affairs article, Commonwealth Fund authors said: “Compared to a Medicare-for-All approach, our [Building Blocks] framework does not achieve the simplicity, consolidated risk, administrative overhead, and provider payment net savings of covering nearly everyone through Medicare.”

Sometimes even Medicare-for-All admirers succumb to the “yes but” syndrome, as in “yes, but Medicare-for-All is politically impractical.” For example, after praising Medicare-for-All, The Health Care Mess concluded that “political reality compels us to ask whether there are not other ways” (besides Medicare-for-All) and answered that question “yes.” Princeton economist Paul Krugman, who had extolled Medicare-for-All in 2006, put a foot in the “yes but” camp in 2007. He welcomed the Edwards, Massachusetts, and Schwarzenegger plans to compel individuals to select from among insurance plans, thereby forgoing Medicare-for-All’s economies. The Edwards and Obama plans required a Medicare-like plan as one option. Krugman argued that such a plan’s lower cost will eventually crowd out more expensive private plans. This overlooks private insurance’s history of cutting prices to gain market share, later returning to double-digit boosts. Also, the Massachusetts program actually is not universal; it omits children, among others, and it is having real trouble meeting its costs. The California legislature as well rejected the “Governator’s” plan as too costly.

Though the political “yes, buts” surrounding Medicare-for-All prove groundless, they deserve discussion. However, the “yes, buts” should not preempt discussion of Medicare-for-All’s substantive advantages, as they all too often do. For example, the May/June 2008 issue of Health Affairs, a 200-page-plus compendium on health reform and expanding coverage, does not contain a single article devoted to Medicare-for-All. In this post, we first describe the advantages of Medicare-for-All, then demonstrate that the evidence behind the political “yes, buts” is exaggerated and flawed.

http://healthaffairs.org/blog/2008/08/28/medicare-for-all-why-we-should-say-yes-not-yes-but/

Professor Bernstein and Professor Marmor are amongst the most qualified and experienced experts on both health policy and the politics of Medicare and social insurance in general. We need to listen to what they have to say. Be sure to click the link above to read their full message.

Everyone knows that the U.S. health care financing system is in critical condition, and that we once again are entering a political window in which reform is possible. Never has it been more important to understand all of our options.

Yet where are we? Those controlling the serious dialogue on reform (e.g., Health Affairs) have limited the options to proposals that would merely tweak our dysfunctional, fragmented system of financing health care, leaving the private insurance industry as the dominant player in health care misfinancing. Perpetuation of our current system will further expand our almost unbearable costs, and leave us far short of the goal of ensuring that every single individual receives the health care that she or he needs.

Health policy is not rocket science. We know precisely what will work. Most in the policy community (including politicians), who believe that we must seize this opportunity for reform, largely agree that a universal, single payer, Medicare-like program would be the most efficient and effective model of reform. And their response?

Yes but… (UNSPOKEN: let’s not even bring that into the discussion).

Talk about health policy malpractice!

Lessons of 401(k) plans for health care

Posted by on Thursday, Aug 28, 2008

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.

Lessons From the Evolution of 401(k) Retirement Plans for Increased Consumerism in Health Care: An Application of Behavioral Research

By Jodi DiCenzo and Paul Fronstin
Employee Benefit Research Institute (EBRI)
August 2008

Retirement and health benefits following a similar evolution:

The private sector’s shift away from “traditional” company-financed pension plans toward individual 401(k) accounts illustrates how benefit decision-making and responsibility have shifted from the employer to the worker. The current trend in health care design toward “consumer-driven” health plans illustrates the same trend with health benefits.

Health plan design is encountering the same obstacles as 401(k)s did:

Efforts to make workers more involved and responsible for their health benefits have run into the same problems that 401(k) plans did: Workers tend to delay or be disengaged from both retirement and health care decisions, these issues require long-term planning, and workers see both retirement and health care decisions as complex and difficult.

Among the behavioral lessons learned from retirement plans:

  • More choice is not always better: Behavioral research, particularly with 401(k) retirement plans, has shown that increased choice can have negative consequences: More is not always better and may even be worse in some cases. Many people remain disengaged from matters they do not have an immediate need to address, and by the time the need becomes immediate, it is often too late. Many, if not most, workers are probably not capable of making the most appropriate retirement planning or health care choices — it is simply too difficult.
  • Education and information are not enough: Research has shown that education has resulted in little to no improvement in workers’ knowledge of retirement saving and investing. In addition, empirical evidence suggests that even when “educated” employees know, most of them fail to act on their knowledge. The heavy investment that many employers have made in retirement education and information programs often fails to produce the desired results.
  • Financial incentives don’t always work: Financial incentives, such as an employer match in a 401(k) plan and tax breaks, also fall short of motivating optimal behaviors. Despite the tax-favored status of contributions and the existence of employer matching contributions, a significant portion of eligible workers still do not contribute to a 401(k) plan.

http://www.ebri.org/pdf/briefspdf/EBRI_IB_08-2008.pdf

The theme of this report is that lessons can be learned from the behavior of employees regarding their individual 401(k) retirement plans that can be applied to their participation in consumer-driven health plans, but the importance of these observations is far greater than merely providing suggestions to “nudge” employees into these programs. The behavioral observations are precisely those that would be anticipated in programs that are designed to shift the responsibility for retirement and health security from the employer to the individual.

Traditionally many employers provided generous health and retirement benefits to their employees. Participation was automatic and was welcomed by the employees as part of their employment compensation packages.

Once employers became concerned about the costs of these programs, they responded by shifting the responsibilities to the individual employees. First the traditional pension plans were shifted to individual 401(k) plans, and now health plans are being shifted to consumer-driven plans, especially health savings accounts or health reimbursement arrangements coupled with a high-deductible health plan. As the authors state, the decisions required tend to be complex and difficult, which tend to delay or disengage the employee from these decisions.

Compare this with Medicare and Social Security. These are retirement and health benefit programs in which enrollment is automatic, and with benefits that are so popular every politician has learned not to touch this third rail.

Employers should be relieved of their responsibility to develop and manage these programs, but placing that responsibility in the hands of each individual would be disastrous. With a median household income of $50,000 most simply cannot afford either adequate health benefit plans or retirement income security. A new study by Elizabeth Warren reveals that this is already at a crisis level – personal bankruptcy for retirees has skyrocketed.

The missing ingredient is social solidarity. Through social insurance programs we could all have both health security and retirement security that is completely automatic. We already have the money. But solidarity? That doesn’t take money; that takes will.

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