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.


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.


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.



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.



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.


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
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.


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
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.


PDF version:

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

  • Comments Off on In Global Recession, Health Care Reform Which Saves Money Is An Economic Imperative

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.

In “A Dangerous Plan for Health Care” Roger Hickey hopes that an advertisement in the New York Times might help rescue private health insurance from its own failings. But where does the danger really lie?

With exuberance Hickey makes a strange assertion: that “the employer-based health care system” in the United States is “the one part of our insurance system that works.”

Say what? Not the Veterans’ Administration, when it boasts the best primary care outcomes in the United States? Not Medicare, when it covers 45 million people yet keeps overhead below 3%?

But Hickey instead issues a false alarm, warning of “dangerous” proposals like those made by McCain, Bush and Company, calling them “ideas off the shelf of right-wing think tanks.” These proposals call for things like federal deregulation of the health insurance industry, taxes on employee health insurance benefits and initiatives based upon personal responsibility — when costly illness strikes … go shopping! (And go bankrupt.)

But these schemes are a joke. Not funny — simply a joke. Such notions, lacking any basis in reality, will not come into reality. They amount to ideological assertions.

Hickey raises the threat of right-wing “reform” because the rhetorical device gives him permission to attempt the impossible: to rush to the defense of employer-sponsored health coverage. Ironically he undermines his conclusions by straying too close to the deplorable facts about private health insurance.

“Those who have insurance are paying higher costs for policies that often have gaping holes in coverage,” Hickey exclaims. “And insurance companies flat-out refuse to sell coverage to those already sick. And businesses, large and small, are burdened with rising costs.” He also bemoans that “millions of dollars the insurance and pharmaceutical industries spend on lobbying and political contributions have only served to prop up a failing system and drown out the voices for change.”

Yet somehow Mr. Hickey draws a crucial distinction between employer-sponsored private health insurance and buying private health insurance as an individual: “dismantling the one part of our insurance system that somewhat works, forcing everyone to buy health insurance on their own, hardly seems a step forward for most people.”

Therefore, he concludes:

“… we need clear rules requiring private insurance companies to cover everyone – even those with pre-existing conditions. And we need the security of knowing we can keep our current health plan, or we can choose a public plan like Medicare, so we’re not at the mercy of the same profit-driven companies that got us into this mess!”

There is some wishful thinking, and some deception too, that if people could only “choose a public plan like Medicare” the public entity could hold the private industry in check, or even that it could grow like Topsy and magically morph into single payer. Yet there is no evidence to support these assertions. The most likely outcome, based upon the bitter experience of several states, as well as the effort to privatize Medicare, would be a failed reform.

To summarize: Hickey argues that the economic crisis and the past failures of private health insurance have renewed a conservative call to dismantle employer-sponsored health insurance. Therefore, the government should rescue the private health insurance industry through regulation. In other words, to answer the conservatives, Hickey offers another ideological assertion, known as Health Care for America Now.

In order to improve the health of the inhabitants of the United States we must rise above a contest of ideological assertions. Meaningful reform will mean measurable progress, facts, evidence. Yes, it will take a social movement. Improving health care must become a question of understanding the evidence — and having confidence that our fellow human beings can and will do the same.

Look at the evidence: reforms based upon regulating and expanding private health insurance have failed, in many forms, many times over many years. This is because because private health insurance stands in contradiction to caring for the sick and preventing illness among the healthy.

A single-payer program is not only eminently feasible (over 40 years ago Medicare was put in place within a year!), but has the economy to save costs by eliminating preposterous administrative waste, reduce disparities by redirecting resources, improve quality by redirecting resources, protect the caregiver-patient relationship by eliminating a tangle of red tape, allow free choice of care providers because if everybody is in and nobody is out then everybody is in — while providing access to care for everyone in the United States.

Because of the evidence, moral imperative is on our side. Society should offer every person the best possible chance at health. The public should set health priorities. Profit-making should be banished when it comes to caring for the sick. Access to health care should not be tied to a job.

Public opinion is on our side. People are ready for a change. It is not only a degree of frustration with insurance companies, but rising expectations about our nation’s promise.

Meanwhile our children need to see a dentist. Our parents need home health aides. Prescription drugs have become a racket. In short, everyday experience makes the case for single payer.

The idea that regulation of private health insurance is the best we might hope for amounts to a dangerous plan for health care. It is a far cry from a “people’s movement” — and it simply will not work.

We need single payer now. HR 676.

Hawaii's "crowd out" crowds out children

Posted by on Monday, Oct 20, 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.

Hawaii ending universal child health care

By Mark Niesse
The Miami Herald
October 17, 2008

Hawaii is dropping the only state universal child health care program in the country just seven months after it launched.

Gov. Linda Lingle’s administration cited budget shortfalls and other available health care options for eliminating funding for the program. A state official said families were dropping private coverage so their children would be eligible for the subsidized plan (Keiki Care).

“People who were already able to afford health care began to stop paying for it so they could get it for free,” said Dr. Kenny Fink, the administrator for Med-QUEST at the Department of Human Services. “I don’t believe that was the intent of the program.”


Although Hawaii’s Keiki Care for uninsured children was promoted as a program that would ensure that all children had health care coverage, it never would have achieved universality, partly because of various eligibility and enrollment issues. Also the coverage was not as comprehensive as coverage under Medicaid. Nevertheless, it did provide limited coverage for about 2,000 of the state’s uninsured children (out of an uncertain number estimated between 3,500 and 16,000).

In designing incremental reform measures, many in the policy community insist that programs must be designed to prevent crowd out. Crowd out is a phenomenon in which individuals will drop out or be pushed out of an existing program, such as employer-sponsored coverage, in order to be enrolled in another program, such as Keiki Care. Administrators who wish to minimize spending in public programs frown upon crowd out.

Although this program is only seven months old, and, to be eligible, children must have been uninsured for at least six months, it is unlikely that crowd out was a significant contributor to the very modest enrollment rates.

Most economists consider crowd out to be undesirable because the numbers of individuals crowded out of existing coverage are subtracted from the total in the alternative program to determine the net gain in numbers covered. That might be important if your only goal were to increase the numbers with coverage, but aren’t there other desirable goals? Hint: In 1966, was it really detrimental that Medicare crowded out coverage in the private insurance sector for those over 65?

Keiki Care is yet another example of an incremental program designed to approach the goal of universal coverage a single step at a time. Although these programs are reported as successes, the long-term trend is that almost all measurements continue to demonstrate deterioration in affordability and coverage.

As long as we continue down the path of patch-work incremental reform, we are going to continue to hear alarms sounded over crowd out, adverse selection, moral hazard, medical loss ratios, investor return, lack of price transparency, high premiums due to excess regulation of private plans, and on and on, and we will never reach our goal of affordable health care for everyone.

It’s time to dump the perverse policies that serve the interests of others, and adopt policies that would serve the interests of patients – a single payer national health program.

Underinsurance in Massachusetts

Posted by on Friday, Oct 17, 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.

The Impact of Health Reform on Underinsurance in Massachusetts: Do the insured have adequate protection?

By Sharon K. Long
Urban Institute
October 2008

In an attempt to protect individuals from underinsurance, as part of that health reform effort Massachusetts established a standard for “minimum creditable coverage” (MCC) that outlines the key benefits that must be included in an individual’s health insurance plan if it is to satisfy the state’s new individual mandate for health insurance coverage. The required benefits, which are intended to protect those with insurance from high health care costs, include preventive and primary care, prescription drugs, a maximum on the annual deductible and a maximum on out-of-pocket spending, among other things.

In brief, underinsurance means that an individual’s health insurance does not adequately protect him or her from high health care costs in the event of a serious illness or accident. A complete assessment of the adequacy of insurance coverage requires detailed information on the coverage and cost-sharing provisions of the individual’s health insurance plan. Given the data available in our survey, we are limited to a narrower focus that considers the individual’s out-of-pocket (OOP) heath care costs. (Note that this is OOP costs for health care beyond the premium that the individual pays to purchase private coverage.) High OOP health care costs provides a conservative, lower-bound estimate of underinsurance as it only captures inadequate insurance coverage for those who had high health care costs in the last year. Consequently, this measure of underinsurance does not include any of the individuals with similar health insurance coverage who did not have high health care costs during the year.

We follow the approach used by Schoen et al. (2005, 2008) and use two standards to assess underinsurance:

(1) Having OOP costs of 10 percent or more of family income–a threshold that has been used in prior studies of underinsurance, and

(2) Having OOP costs of 5 percent or more of family income for low-income families (defined as those with family income less than 200 percent of poverty)–a threshold for financial risk that is consistent with cost-sharing provisions in the State Children’s Health Insurance Program (SCHIP).

Given the limitations of our data, the measure of underinsurance reported here provides a conservative measure of the extent of underinsurance in Massachusetts.

Drop in Underinsurance. In fall 2006, at least 4 percent of all working-age adults with full-year insurance coverage in Massachusetts were underinsured under the first definition of underinsurance (10 percent or more of family income in OOP health care costs) and at least 7 percent were underinsured under the second definition. Under health reform, the share of insured adults who were underinsured under both definitions dropped by about 2 percentage points between fall 2006 and fall 2007, down to about 3 percent and 6 percent underinsured, respectively.


Results restated in a summary by The Commonwealth Fund:

In fall 2006, 7.3 percent of all Massachusetts adults were underinsured (using the definitions above: out-of-pocket costs equal to 10% or more of income for higher-income people, 5% or more for lower-income people). After the enactment of health reform, that share declined to 5.6 percent.


Many news reports now tout the success of the Massachusetts health care reform program in reducing the numbers of the uninsured, even though falling far short of universal coverage. This new report also suggests that the rate of underinsurance may have declined, an important point since it was feared that efforts to make the plans more affordable would defeat the financial security that the plans should provide.

Massachusetts already had higher regulatory standards for their insurance products, but to be certain that coverage would be adequate under this program, they established a standard for “minimum credible coverage,” with benefits “intended to protect those with insurance from high health care costs.” How well has that worked?

Using estimates that omit many instances of underinsurance, this study shows that the rate of underinsurance is still over three-fourths of the rate that existed before the program was initiated. A program that eliminates less than one-fourth of the problem targeted should not be considered a successful program.

Of particular concern is that those individuals who are currently healthy, the majority of all insured, were not considered to be underinsured even if their coverage is not adequate to protect them against financial hardship should they develop significant medical problems in the future. Since one of the most important functions of insurance is to protect against unforeseen losses, the incidence of underinsurance is far greater than this study would indicate.

Massachusetts really needs to take another look at the single payer model of reform. By design, single payer includes everyone and eliminates the financial hardships of underinsurance. Their current reform model will always fall short of those goals.

About this blog

Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.

News from activists

PNHP Chapters and Activists are invited to post news of their recent speaking engagements, events, Congressional visits and other activities on PNHP’s blog in the “News from Activists” section.