Medical tourism causes complications

Posted by on Thursday, Oct 30, 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.

Medical Tourism Causes Complications

By Christina L. Madden
Carnegie Council
Policy Innovations
October 27, 2008

Approximately 750,000 Americans traveled overseas for medical treatment in 2007, and the number of so-called medical tourists could increase to more than 15 million in 2017.

Overall the effects of medical tourism are mixed. On the one hand, the industry can boost a developing country’s gross domestic product and investment in health facilities. Upgrades in a country’s hospitals also tend to decrease external brain drain, as top physicians find local jobs instead of leaving for employment in developed nations.

In many cases, however, medical tourism threatens to exacerbate unequal access to quality health care in developing countries. Although relatively cheap by most Western standards, the private hospitals that treat foreigners are out of reach for the majority of people, and the revenue they bring in rarely makes its way to the public sector.

External brain drain is often replaced by internal brain drain, as doctors leave public health care centers to work in private hospitals.

Medical tourism is not an alternative to significant reform of the U.S. health care industry. Aside from the negative effects on public health overseas… medical tourism is not predicted to reduce the country’s health spending by more than 1 to 2 percent.

By introducing global competition to an industry that’s long been considered immune to outsourcing, medical tourism may up the ante on reforming coverage, cost, and quality at home.

http://www.policyinnovations.org/ideas/briefings/data/000083

Previous studies have shown that one of the reasons that health care is so expensive in the United States is that, quite simply, our prices are very high. Since other nations have been demonstrated to be capable of selectively providing high quality care at much lower prices, it is not surprising that medical tourism has become an attractive option for those paying the bills, including cash-paying patients, some insurers and some employers.

For those who believe that health care financing should be a function of markets, medical tourism would have a prominent place in the menu of options. For those who believe that health care systems should provide everyone with the best options available in an egalitarian system, both for us in the United States and for the people of other nations, medical tourism is a troublesome development.

As this article describes, medical tourism is further impairing public health programs in developing nations. In our quest for a high performance system in the United States, we must be very careful to avoid the unintended consequence of inflicting damage on the health systems of other nations.

The World Health Report 2008

Posted by on Wednesday, Oct 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.

Primary Health Care – Now More Than Ever

World Health Organization
October 14, 2008

The World Health Report 2008 critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The WHO report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.

Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.

To steer health systems towards better performance, the report calls for a return to primary health care (PHC), a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment.

This report structures the PHC reforms in four groups that reflect the convergence between the evidence on what is needed for an effective response to the health challenges of today’s world, the values of equity, solidarity and social justice that drive the PHC movement, and the growing expectations of the population in modernizing societies: reforms that ensure

  • that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection — UNIVERSAL COVERAGE REFORMS;
  • reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes — SERVICE DELIVERY REFORMS;
  • reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors — PUBLIC POLICY REFORMS;
  • reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems — LEADERSHIP REFORMS.

In high-expenditure health economies, which is the case of most high-income countries, there is ample financial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established universal coverage system with targeted measures to reduce exclusion.

Even in the United States, its exceptionalism stems not from lower public expenditure… but from its singularly high additional private expenditure. The persistent under-performance of the United States health sector across domains of health outcomes, quality, access, efficiency and equity, explains opinion polls that show increasing consensus of the notion of government intervention to secure more equitable access to essential health care.

http://www.who.int/mediacentre/news/releases/2008/pr38/en/index.html

Primary Health Care – Now More Than Ever (148 page PDF):
http://www.who.int/whr/2008/whr08_en.pdf

The World Health Report 2008 provides a critical assessment of health care systems throughout the world. It describes how all nations, regardless of national wealth, can benefit by enacting reforms organized around primary health care.

In reading the various experiences of other nations, it is almost shocking to see how infrequently the most expensive health system of all, that of the United States, is mentioned as an example of how reform can work. But then it is understandable when other nations single our system out for its exceptionalism – a system with “singularly high additional private expenditure” that persistently underperforms “across domains of health outcomes, quality, access, efficiency and equity.”

For a proper perspective of what we do have and what we could have, this report should be required reading.

California's high-risk pool is sick

Posted by on Tuesday, Oct 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.

California high-risk pool for medically uninsurable helps fewer residents

By Jordan Rau
Los Angeles Times
October 28, 2008

California… is one of 35 states that arranges health coverage for people rejected by commercial companies because they have blemished medical histories.

This group — known as “medically uninsurable” — accounts for about an eighth of the 5 million Californians who lack health insurance. Most are self-employed, work for companies that don’t provide insurance or don’t have a job.

But California’s publicly subsidized high-risk pool, long one of the least generous in the country, has atrophied over the tenure of Gov. Arnold Schwarzenegger — even as the governor put the plight of the uninsured at the top of his political agenda.

Rising premiums and limited subsidies have made the Major Risk Medical Insurance Program either unaffordable, unavailable or ineffective for many of those who most need health insurance.

The program now covers about 13,000 Californians — about 2% of the medically uninsurable.

Enrollment has dropped by almost a third since Schwarzenegger became governor.

Subscribers pay two-thirds of the pool’s cost and the state about one-third. The insurers that voluntarily participate — primarily Blue Cross of California and Kaiser Permanente — break even.

Unlike most other states, which finance their programs either directly with tax dollars or with assessments on insurers, California’s subsidies have come only from the state’s tobacco tax.

Lawmakers have kept annual financing at or below $40 million a year, requiring the pool’s administrators to cap its enrollment.

One of the major obstacles is the cost of premiums, which the law sets at 125% of commercial insurance rates. More than a third of pool participants who dropped out this year told the pool’s administrators that they couldn’t afford it anymore.

Despite its cost, California’s high-risk pool is of limited use for people needing extensive medical care, such as those with cancer or chronic diseases. That is because the pool’s benefits are capped at $75,000 a year, lower than the limits of any other state’s pool.

To fix California’s pool, the Legislature this year proposed placing a $1 monthly per customer fee on insurers that sell policies directly to customers.

But in his veto message, Schwarzenegger said the fee would be passed on to customers and thus “only exacerbates their burden.”

http://www.latimes.com/news/local/la-me-uninsured28-2008oct28,0,7559850,full.story

The concept of health insurance is quite simple. When everyone pays into an insurance risk pool, the many who are healthy are subsidizing the higher costs of those with greater health care needs. Thus everyone receives whatever medical care they need without facing financial barriers to care.

Then why do we have high-risk pools? The simple answer is that health care has become so expensive that premiums for universal pools would be so high that few could afford them. So we move higher cost individuals into high-risk pools in order to keep premiums more affordable for pools of healthy individuals.

Think about the premium for a family in an employer-sponsored pool composed of the healthy workforce and their young healthy families; it now averages $12,600. If we were to add into these pools many hundreds of thousands of individuals with high health care costs, you can only imagine how high the premiums would go.

Although California has set the high-risk pool premium at 125 percent of commercial rates, they have had to cap the benefits at $75,000 to avoid yet higher premiums. Sorry, but for this high cost group, that falls far short of the insurance function of preventing financial hardship in the face of medical need. For adequate benefits, the premiums for high-risk pools would be unaffordable for all but the very wealthiest of us, as if they weren’t too high already.

If we expect to cover high-risk individuals, we do need a transfer from the healthy to the sick. California attempted to take a very small step in this direction by assessing fees on insurance plans in the individual market that would be used to help fund the high-risk pool. But Gov. Schwarzenegger didn’t want to “exacerbate the burden” on the healthy by expecting them to help fund care for the sick. Then who funds the high-risk pool?

We really need to end this game of juggling unaffordable premiums amongst fragmented, inequitable risk pools. It’s time to establish one single risk pool for all of us, and fund it equitably through progressive taxes. The private plans get in our way. We need to dump them.

U.S. rationing eliminated by hallway admissions

Posted by on Monday, Oct 27, 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.

‘Hallway medicine’ seen as a way to unclutter ERs

By Carla K. Johnson
Houston Chronicle/AP
October 26, 2008

It may not sound like ideal health care, but hospital officials nationwide are being urged to consider hallway medicine as a way to ease emergency department crowding, and some are trying it.

Leading the way is Stony Brook University Medical Center at Stony Brook, N.Y., where a study found that no harm was caused by moving emergency room patients to upper-floor hallways when they were ready for admission.

Holding patients in ERs can cause deaths, doctors say. In a 2007 survey of nearly 1,500 emergency doctors, 13 percent said they personally experienced a patient dying as a result of boarding in the emergency department. The survey was conducted by the American College of Emergency Physicians.

The new study found slightly fewer deaths and intensive care unit admissions in the hallway patients, compared with the standard bed patients. That was no surprise… because the protocol calls for giving the first available rooms to the sickest patients. Intensive care patients never go to hallways.

http://www.chron.com/disp/story.mpl/health/6079406.html

The United States has 2.9 hospital beds per 1000 individuals. The median number of beds for OECD nations is 3.7 (OECD, 2002). Not only do we have fewer beds, the distribution is less even than in other nations with their more egalitarian systems. The supply of beds tends to be quite adequate in affluent regions, but is inadequate in other areas, especially those served by safety-net institutions.

In many hospitals, emergency departments have had to accept queues in “holding” – patients who have been admitted but for whom there are no beds available on the hospital floors. When the holding area is full, it has been common practice to admit patients to the hallways of the various services, not as policy but as a temporary inconvenience. The significance of this study is that hallway admissions now are being recommended as explicit hospital policy.

Hospitals also need policies to provide surge capacity – the ability to admit much larger numbers of patients in the event of major epidemics or catastrophic events. Can you imagine how these hospitals would respond to such a surge in patients? Not very well.

How is it that we have lower capacity and worse distribution of our hospital beds than do other nations that spend much less on health care than we do? Quite simply, they use equitable, egalitarian systems for health care financing and health system planning. Of course, this is code language for stating that they depend on government involvement in their financing and health system planning.

Other nations do sometimes have queues, especially for less urgent problems, often labeled as rationing. So their systems are not perfect. Some merely need to spend more money, and others need to replace their public stewards with individuals who have more egalitarian values.

In the United States, we spend more than enough money, primarily on those with the means to pay, and they get good care (except for an excess of detrimental high-tech services).

In contrast, for less affluent individuals, we do not even supply them with enough beds. But at least we don’t ration. We merely hide them behind the curtains in the upstairs hallways.

Sen. Kennedy's grand finale

Posted by on Friday, Oct 24, 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.

Kennedy secretly crafts health care plan

By Jeffrey H. Birnbaum
The Wilmington Times
October 24, 2008

From his sickbed, Sen. Edward M. Kennedy has secretly been orchestrating meetings with lobbyists and lawmakers from both parties to craft legislation that would greet the new president with a plan to provide affordable medical coverage to all Americans, a measure he has called “the cause of my life.”

Among those who are receptive to a bipartisan plan and who have participated in the initial talks is Sen. Michael B. Enzi of Wyoming, the ranking Republican on the Senate health committee, which Mr. Kennedy leads.

Mr. Kennedy’s goal, his aides say, is to introduce a universal health care bill as soon as the new Congress convenes next year and to push quickly for its passage – a much-accelerated timetable compared with the last time that a health care overhaul was on the agenda, at the start of the Clinton administration.

The wide-ranging talks have taken place behind closed doors on Capitol Hill and have been monitored by Mr. Kennedy through daily telephone updates from his staff, said his aides and several participants.

The discussions, which started in June, included 14 roundtable meetings in the Dirksen Senate Office Building. These were attended not only by Kennedy aides but also by staffers, both Republicans and Democrats, from the Senate committees with jurisdiction over health care. Those include the Budget Committee, the Finance Committee and the committee that Mr. Kennedy leads, the Committee on Health, Education, Labor and Pensions.

Also attending was the entire panoply of interest groups with stakes in the cost and availability of health coverage. These included the AFL-CIO, the Business Roundtable, the U.S. Chamber of Commerce, the National Federation of Independent Business, the National Retail Federation, the Federation of American Hospitals, the American Medical Association, America’s Health Insurance Plans, Families USA, AARP and the Consumers Union.

The talks have managed to put in the same room interests that rarely meet – let alone agree with one another. No one is under the illusion that finding a compromise will be easy. Indeed, it remains unclear that a long-elusive consensus can be found. Participants agree, however, that Mr. Kennedy’s active role – particularly during his convalescence – have increased the likelihood of a breakthrough.

http://www.washingtontimes.com/news/2008/oct/24/kennedy-secretly-crafts-health-care-plan/

Everyone has profound admiration for Sen. Edward Kennedy’s valiant effort to finally overcome the stubborn political barriers, and bring health care to everyone in the nation. At a time that the people are demanding reform, Sen. Kennedy is positioned to provide us with his grand finale – and what a great one that would be – health care for everyone.

But what a task he has. He is working with individuals and organizations that have rigid policy positions, which they demand be a part of any reform package. Many of these positions are absolutely incompatible with each other and could never be incorporated together in a legislative package. Most of these policy positions represent either special interests or simple ideology.

If this process is to work, all of these interests will have agree to policies that place the interests of patients above all else. The goal must be to establish a system in which everyone can receive all necessary health care without the necessity of facing financial hardship. We know how to do this. The policies are easy; the politics aren’t.

We pray that Sen. Kennedy can produce a grand finale in which all special interests realign themselves to support the only interest that really matters – the American patient.

Los Angeles Times series on private insurers

Posted by on Thursday, Oct 23, 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.

An eroding model for health insurance

By Lisa Girion and Michael A. Hiltzik
Los Angeles Times
First of three parts
October 21, 2008

The health insurance system has become increasingly expensive and inaccessible. It leaves patients responsible for bills they understood would be covered, squeezes doctors and hospitals, and tries to avoid even minuscule risks, such as providing coverage to a newborn with no serious illness.

At the heart of the problem is the clash between the cost of medical care and insurers’ need to turn a profit.

During her pregnancy, Jennifer Danylyshyn’s regular visits to her obstetrician were covered by her Blue Shield policy. So was the delivery of Ava on March 24. The couple expected that Ava would be covered as a matter of course.

When the company rejected the baby because of the hip misalignment, her parents appealed with the help of their pediatrician.

Blue Shield refused to budge.

http://www.latimes.com/business/la-fi-insure21-2008oct21,0,2292699,full.story

And…

Health insurers reinvent themselves as money managers

By Michael A. Hiltzik
Second of three parts
October 22, 2008

WellPoint Inc., the nation’s largest health insurance company, ran into a snag last year while pursuing an important new business initiative.

Federal banking regulators insisted on classifying WellPoint as a healthcare company. And that was interfering with its efforts to open a bank.

The Federal Reserve Board eventually agreed that the company’s core insurance business could be considered financial services.

That a medical insurer would agree to keep a lid on healthcare expenditures so it could get approval to open a bank illustrates a fundamental change in the industry: Insurers are moving away from their traditional role of pooling health risks and are reinventing themselves as money managers — providers of financial vehicles through which consumers pay for their own healthcare.

Because he has high blood pressure, (Alex Kipper, an engineer who lost his employer-provided health insurance during the dot-com bust) found himself virtually uninsurable. Fearing that he could be financially wiped out in a medical emergency, he signed up for a bare-bones policy that provides no coverage until his medical expenses exceed $8,000 in a year.

His health plan’s concession to preventive care was a $25 discount on a physical. Once diagnostic tests were included, the fee for the checkup came to more than $300, Kipper said — which the health plan declined to pay.

He hasn’t returned to a doctor’s office in three years.

Although the policy costs only $200 a month, “nothing is covered, absolutely nothing,” Kipper said.

http://www.latimes.com/business/la-fi-insure22-2008oct22,0,3603421,full.story

And…

The battle of the medical bills

By Daniel J. Costello, Lisa Girion and Michael A. Hiltzik
Third of three parts
October 23, 2008

“Insurers have found a very creative way of denying, delaying or slowing payments in a way that is having a real impact on patient care and some of our survival,” said Von Crockett, Centinela’s chief executive. “Every single doctor and hospital is writing off money they are legally owed but don’t collect. It’s an insane situation.”

In June, the American Medical Assn. released its first rating of insurers’ billing patterns. It found that United Healthcare paid physicians the contracted fee 62% of the time, Aetna paid 71% of the time and Medicare paid 98% of the time.

Dotti Smith, office manager for a group of surgeons affiliated with St. Mary’s Hospital in Long Beach, recently billed a major insurance company for a gallbladder operation. The insurer had preauthorized the surgery and the surgeon was a member of the insurer’s network of preferred physicians, Smith said. But the company refused to pay the $3,100 bill.

Why? The patient was enrolled in a subcategory of coverage with a smaller network of doctors that did not include the Long Beach surgeon.

http://www.latimes.com/business/la-fi-insure23-2008oct23,0,4914143,full.story

This important series of three articles published this week in the Los Angeles Times explains why the private insurance industry has neither the efficiency nor the moral authority to continue to manage our health care dollars. Each of the excerpts above provides an example of the management perversities of the industry, along with an example of the impact on a real-life patient. Much more can be found in the articles.

The private insurance industry has shifted from an amoral business model selling us administrative services to help manage our health care spending, to an immoral racketeering industry that is threatening the health and financial security of all of us.

We desperately need to reform health care financing in the United States, but not with a model that keeps these crooks in play.

Fragmentation of family health care

Posted by on Wednesday, Oct 22, 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.

Uninsured Children and Adolescents With Insured Parents

By Jennifer E. DeVoe, MD, DPhil; Carrie Tillotson, MPH; Lorraine S. Wallace, PhD
JAMA
October 22/29, 2008

The association between coverage for parents and their children has been widely reported. When entire families have access to health insurance, children and adolescents not only benefit from more consistent insurance coverage but also have improved access to a regular source of care and higher rates of preventive services. If entire families cannot gain consistent coverage, it is most often their children who have insurance while the parents go uncovered, especially since the creation of the State Children’s Health Insurance Program (SCHIP). Less is known, however, about how commonly this pattern is reversed.

Although the weighted results of this survey indicated that the largest group of uninsured children and adolescents had uninsured parents, an estimated 27.9% of the uninsured children and adolescents had parents with health insurance. When weighted, these estimates represent 3 million children who had a coverage gap despite having at least 1 parent who had full-year coverage. More than a million of these children were without coverage for the entire year.

Evidence suggests that when family members are covered separately under different plans or when certain individuals have coverage and others do not, children’s health declines. Furthermore, if the assumption that insurance coverage is a “household good” is abandoned and the system shifts toward defining it as an “individual good,” we add layers of complexity for vulnerable families who must simultaneously learn different systems for enrollment and utilization of multiple insurance plans. Discordant patterns of family health insurance may become the norm rather than the exception; the current trend is certainly moving in that direction.

If families are better off covered under one plan but US society rejects a public health insurance program for all members of the family, the question of whether the employer-based model is sustainable may need to be revisited. In this study, the private system did not do a good job of providing coverage for entire families.

Incremental expansions in public insurance programs for children will continue to improve insurance rates in the short term. However, the longer-term solutions to keeping all children insured are likely to be more complicated. Unless health insurance coverage models are designed to keep entire families covered, some children will continue to get left behind.

http://jama.ama-assn.org/cgi/content/full/300/16/1904

It has long been recognized that one of the deficiencies of the children’s health insurance program (SCHIP) is that parents in these lower income families often remain uninsured. This study demonstrates that the reverse also occurs. Even though one or both parents may be insured, often through their employment, the children may be left without coverage, primarily due to eligibility and affordability issues.

This study also reinforces the principle that simply increasing the numbers of insured through patchwork programs is not an adequate goal. Our goal should be to ensure comprehensive, coordinated, continuous care for each individual and each family by establishing equitably-financed medical homes for everyone.

Stable, continuous, coordinated family care is almost impossible under the current system. Both employer-sponsored and individual private plans continue to change based on employment status, employer decisions on plans, variations in participation in provider networks, comprehensiveness of the benefits, employee ability to contribute to the premium, and other factors largely not under control of the individual. Public programs also have similar variations in networks and coverage, and, in addition, have changing eligibility requirements for enrollment sometimes related to legislative and administrative budget decisions.

Today almost no family has the same stable coverage for all family members from birth until the children leave the home (and for the parents after the children have left). Nor can they be assured that they will be able to continue their care with the same physicians, hospitals and other health care professionals.

The future looks bleak. Congressional leaders have promised to expand the SCHIP program, which will tend to perpetuate the instability and fragmentation of care. Then they will begin the effort to patch together the great multitude of private plans into some semblance of a social insurance program. They will fail miserably because the U.S. private plans, based on a business model, have no glue to hold them together. The private insurers will continue to fight to insure only the healthy – the eighty percent of people who use only twenty percent of health care – while selling us an excess of superfluous administrative services. They will dump on us most of the actual costs of health care – the eighty percent of health care spending – through taxes, cost shifting, or simply relying on our stretched-thin charity.

It is astounding that the policy community continues to pursue these fragmented, incremental reforms that pump up costs while leaving health care in a tattered, dysfunctional state. With a single payer national health program, at least the entire family would have affordable access to the professionals and hospitals of their choice. That would be a great start.

Marcia Angell on U.S. lessons for Canada

Posted by on Tuesday, Oct 21, 2008

Privatizing health care is not the answer: lessons from the United States

By Marcia Angell, MD
Canadian Medical Association
CMAJ
October 21, 2008

There are strong moves within Canada to make the Canadian health care system more like the US system by partially privatizing it. Those who favour this approach claim that the US system offers more choice and better quality of care and spares the public purse. Some proponents even go so far as to claim that it is more efficient. My purpose here is to disabuse Canadians of these myths by taking a close look at how the US system works and comparing it with the Canadian system.

http://www.cmaj.ca/cgi/content/full/179/9/916?etoc

PDF version:
http://www.cmaj.ca/cgi/reprint/179/9/916

Those who are well informed on health policy are quite aware of the advantages and disadvantages of the health care financing systems in both the United States and Canada. Although the greater effectiveness and efficiency of the Canadian single payer system are well understood by supporters of a national health program in the United States, there has been a reluctance to use the positive features of the Canadian experience as an example of what we could achieve here. Why? Inevitably, bringing up Canada results in challenges that are a distraction from the primary message on reform.

The opponents of reform in the United States, along with their reactionary Canadian colleagues, are driven by ideology. They will not allow health policy science to interfere with their anti-government message. They do not seek the truth. Instead, they craft messages that paint a terribly inaccurate picture of the Canadian health care system. Sometimes their messages are based on exceptions or on minutia that may represent real problems, but then they present those facts as if they taint the entire health care system with rot. Other times, they simply do not tell the truth. You can cite several examples of lies that have been told so often about the Canadian system that they have been accepted as the truth here in the United States.

This is why Marcia Angell’s article is so important. She presents a broad overview of the two systems, explaining why the U.S. system is so expensive yet ineffective when compared to the Canadian system. She does address some of the failings in Canada, but also explains why the Canadian financing system is better equipped to address those problems than is the dysfunctional, fragmented U.S. financing system.

This article should be downloaded so that it can be used to help inform those who have been misled by the intense anti-government propaganda campaign of the opponents of single payer reform.

It is now widely recognized that we are in a global recession of historic proportions, raising comparisons with the Great Depression of the 1930s. The failures of deregulated markets, whether in housing, banking or other industries, has become obvious to all. So far the private health insurance industry has not been called to account, but its day is coming soon.

As the country grapples with an economy in free fall and as discussions of federal bailouts of financial institutions go forward, what are we doing about health care reform, an industry which consumes over 16 percent of our GDP? In short, not enough. The two presidential candidates have incremental proposals which would cost more and still not provide universal access to health care.  Both would prop up a failing insurance industry as if it provided added value over public financing.

The Lewin Group has just completed an analysis of the Obama and McCain proposals. The Obama plan would try to increase regulation of the insurance industry (which has never been effectively done), would expand and further subsidize public markets, and would offer a new public option modeled after the Federal Employees Health Benefit Plan (FEHBP), which all members of Congress have (its premiums are going up by 13 percent in 2009). The McCain proposal  would reduce regulation over insurance markets, expand the use of tax credits, and subsidize new high-risk pools (which already haven’t worked well). The Obama proposal would reduce the projected number of uninsured Americans of  48.9 million in 2010 by 26.6 million if fully implemented in that year, while the McCain proposal would reduce that number by 21.1 million.  And at what cost?  – – – $1.17 trillion from 2010 to 2019 for the Obama plan and $2.05 trillion for the McCain plan.

We already know that deregulated health insurance markets do not work in the public interest.  We will never get affordable health care for all Americans by propping up its role.  These examples show how much it fails comparisons with public financing (traditional Medicare) in terms of efficiency, costs, value, and equity.
•  Administrative overhead five to nine times higher than Medicare
•  Benefits reduced by medical underwriting vs standard benefits for all Medicare beneficiaries
•  Avoids coverage of sicker people, while Medicare covers all eligibles
•  Profiteering on backs of insured, with allegiance to shareholders,  versus not-for-profit Medicare
•  Fragmentation of insurance pools into many thousands of smaller risk pools by 1,300 private insurers versus one risk pool of 300 million Americans
•  Much larger bureaucracy (eg. while its market fell by 1 percent between 2000 and 2005, the private insurance workforce grew by one-third, mostly involved with “denial management”)

While the so-called “debate” over health care reform heats up in political dialogue, the only real option to reform health care – – – single-payer national health insurance (NHI) – – – is being largely overlooked. It is a hidden fix in plain view, but politicians and the media still remain beholden to corporate interests which profit from a deregulated health care marketplace. Compared to the proposals of both presidential candidates, NHI will actually SAVE MONEY (about $350 billion a year) while assuring universal access to care for everyone. This saving is made possible by administrative simplification, shifting to a not-for-profit mode, bulk purchasing of drugs, medical devices and other medical supplies, and elimination of waste by not covering harmful or ineffective services.

The gains to our country will be immense with NHI.  All Americans will have a new sense of security about their own health care, morale will improve, and social solidarity will be advanced.  U.S. business also has much to gain.  Employers will pay less than they do now to insure their workers, will have a healthier workforce, and will be better able to compete in global markets.  So given our serious economic downturn, don’t we now have an economic imperative, combined with our long-standing moral imperative, to enact a not-for-profit public financing system for health care, coupled with a private delivery system?  Such a plan is not radical or utopian; it is conservative in being more efficient,  less expensive, and offering more value than what we now have. NHI is not socialistic, in the same way that public financing of schools, police, fire protection, Medicare, and the Veterans Administration are not.  And it can do much more for the country than spending billions to bail out industries that have proven themselves unworthy of public investment.  We all have an opportunity in the next weeks and months to force a new Congress to do the right thing.

_______________________________________________________________________

Adapted from Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008 by John Geyman. With permission of the publisher, Common Courage Press

Buy Do Not Resuscitate: http://www.commoncouragepress.com/index.cfm?action=book&bookid=376

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As the recession (?depression) unfolds, the state’s financial crisis will surely deepen. Inevitably, further health budget cuts lie ahead. Unfortunately, the first round of cuts follows the same pattern pursued by the Patrick administration in the past: loudly declare your concern for the poor, while quietly shredding the health care safety net they depend on.

A little noticed feature of the first stage of health reform shipped additional millions of Medicaid dollars to the rich and powerful teaching hospitals and drained them from primary care. In a widely trumpeted move the state upped Medicaid rates for inpatient care – a change that mainly benefited Partners and other financially healthy institutions that provide expensive tertiary care services. (In 2007, the MGH reported a surplus of $354 million, while Brigham and Women’s Hospital had a surplus of $48 million in the second quarter of 2008). But at the same time Medicaid and free care pool payments for outpatient services were shrunken, dealing a body blow to cash-strapped institutions that provide a large volume of primary care to the poor.

On top of this, the state withheld tens of millions promised in the legislation to Cambridge Health Alliance (CHA) (disclosure – that’s where I work) – the only public hospital system left in the Commonwealth. The cash shortage has already cost CHA millions in interest costs.

The latest round of cuts inflicts further wounds on CHA and Boston Medical Center – the other large safety net provider in eastern Massachusetts. Not only will Medicaid rates for the future be cut, the state is demanding a refund of $100 million from past payments to those two systems.

At CHA we’re seeing more uninsured patients than ever, but our funding from the state has been slashed by tens of millions. In the second quarter of 2008 alone we lost $25 million, hundreds of health workers have already been laid off and clinic closures are in the offing.

In the months ahead, tens of thousands of workers in Massachusetts will lose their jobs – and their health insurance coverage. Many will need safety net and subsidized care. The costs of subsidized coverage under Commonwealth Care will predictably rise and the state’s fiscal condition will deteriorate even further. The promise of universal coverage will be broken – and the safety net that cared for the uninsured for decades before health care reform will be left a shadow of its former self.

What are the alternatives? In the short term: cut from the wealthy teaching hospitals that have been racking up huge surpluses for years, rather than the poor ones that are already staggering. In the long term: implement a single payer system that saves billions on profit and bureaucracy, and use the savings to cover the poor and to upgrade coverage for the rest of us.

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