Bayh howls with the Blue Dogs

Posted by on Monday, Mar 23, 2009

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

Moderate Senate Dems Launch New Group to Shape Public Policy

U.S. Senator Evan Bayh
Press release
March 18, 2009

A diverse group of 16 Senate Democrats today announced the formation of a new moderate coalition that will meet regularly to shape public policy. The group’s goal is to work with the Senate leadership and the new administration to craft common-sense solutions to urgent national problems.

Leading the new group are Democratic Senators Evan Bayh of Indiana, Tom Carper of Delaware and Blanche Lincoln of Arkansas. All three leaders are honorary co-chairs of Third Way, a progressive Democratic policy group, and Senators Bayh and Carper have led the centrist Democratic Leadership Council.

In addition to Senators Bayh, Carper and Lincoln, others joining the group are Senators Mark Udall and Michael Bennet of Colorado, Mark Begich of Alaska, Kay Hagan of North Carolina, Herb Kohl of Wisconsin, Mary Landrieu of Louisiana, Joe Lieberman of Connecticut, Claire McCaskill of Missouri, Ben Nelson of Nebraska, Bill Nelson of Florida, Mark Pryor of Arkansas, Jeanne Shaheen of New Hampshire, and Mark Warner of Virginia.

… the Moderate Dems are joined by a shared commitment to pursue pragmatic, fiscally sustainable policies across a range of issues, such as deficit containment, health care reform, the housing crisis, educational reform, energy policy and climate change.


For Blue Dogs, Health Budget Raises Questions of ‘When,’ Not Just ‘How’

By David Clarke
March 16, 2009

As the congressional budget panels prepare to write their fiscal 2010 blueprint, members of the Blue Dog Coalition of fiscally conservative Democrats want to make sure that any expansion of health care coverage is fully paid for–and that its tax or spending offsets are guaranteed to yield savings down the road.

Leaders of the 51-member coalition wrote to the House and Senate Budget committees as well as congressional leaders stating their support for President Obama’s goal of offsetting the cost of a planned health care overhaul. But the Blue Dog leaders said they do not want the savings to be achieved too far in the future if new spending in the short term is going to exacerbate already high federal deficits.

“While we agree that reforming our health care system will eventually lead to savings, it would be irresponsible to take on additional large-scale deficit spending in the short term without the ability to definitively quantify future savings,” Blue Dog leaders wrote March 13 in a two-paragraph letter.

The Blue Dogs are major boosters of the congressional “pay as you go” budget rule that requires new mandatory spending or tax cuts to be fully offset with increases in revenue or spending cuts elsewhere.

The Blue Dog coalition in the House of Representatives has often assisted Republicans in preventing the advancement or even the introduction of progressive legislation that increases government spending. Supposedly their mission is merely to avoid deficit spending by enforcing “paygo” rules (all new spending is offset with other program cuts or with new revenues), but all too often they seem to not only support elimination of deficit spending, but also the policy of “no new taxes.” It appears that they are not only concerned about deficits, but they also seem to want to avoid an increase in the size of the federal budget.

Now Sen. Evan Bayh and fifteen of his colleagues have decided to establish a Blue Dog-type coalition in the Senate. In an obvious effort to wield more power from the middle, they “are joined by a shared commitment to pursue pragmatic, fiscally sustainable policies across a range of issues, such as… health care reform…” Ouch!

Although most observers of the Washington political scene believe that the make or break on comprehensive health care reform will occur in the Senate, there are enough Blue Dogs in the House to not be discounted as major players since they could side with the Republicans if new taxes are used to comply with paygo.

But look at what has happened in the Senate. The moderate Democrats are no longer passive observers (not that they ever really were). Now with their newfound power, the battle for cloture has shifted. Instead of Democrats simply requiring one or two Republican votes to invoke cloture, they must also meet the demands of these sixteen Senate Blue Dog look-alikes. The Republicans now not only have one vote to spare on preventing cloture, they also have a very large buffer in the Democratic Party to prevent comprehensive tax-and-spend health care reform.

There goes any adequate government option to the private plans – “because of adverse selection, we can’t pay for it.” There goes adequate subsidies for private plans for average-income Americans – “without new taxes, we can’t pay for it.” There goes adequate regulatory oversight for the private plans – “unless we have high deductibles and stripped down benefits, the people can’t pay for the plans.”

Single payer would provide the Blue Dogs with the reform they want, or should want. Health care budgets would be balanced without increasing spending over our current level. They just have to understand that funneling health care dollars through our tax system is more efficient than turning them over to private insurers. They need to look at all dollars going into health care, and not just the public dollars.

Real life medical debt bankruptcies

Posted by on Friday, Mar 20, 2009

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

Bankruptcy filings soared in 2008

By Darrell Smith
The Sacramento Bee
March 17, 2009

Bankruptcy filings in Sacramento and the Central Valley continue to soar as weary residents seek relief from the grip of foreclosures and rising unemployment.

More than 31,000 personal and business bankruptcy petitions were filed in the Eastern District of the U.S. Bankruptcy Court in 2008, an increase of 79 percent over 2007’s filings, according to a report released by the federal court.

The caseload is such that callers to the U.S. Bankruptcy Court in Sacramento are greeted with a message that says clerical staff are too busy to speak with them.

“We have never experienced increases with the number of percent we’re seeing,” said Richard Heltzel, clerk at the U.S. Bankruptcy Court for the Eastern District of California, based in Sacramento.

“With unemployment comes the loss of health insurance – so many of our bankruptcies are triggered by uninsured health care costs,” Heltzel said. “I expect to see close to 40,000 cases this year.”

Landmark studies have confirmed beyond any doubt that medical debt is a significant contributor to personal bankruptcy. Yet the opponents of comprehensive reform continue to challenge the data. In the report of John Goodman and his colleagues discussed in yesterday’s message, they stated, “Well-designed economic studies have found no statistical link between bankruptcies and health problems.”

Richard Heltzel, clerk at the U.S. Bankruptcy Court for the Eastern District of California, is not a health policy wonk. His only qualification is that he sees the health care costs listed in the personal bankruptcy filings.

Medical debt is a very real problem, faced by very real people, and it really does contribute to personal bankruptcy. Fortunately, most in Washington seem to understand that now, even if they disagree on what we are going to do about it. We can tell them how this problem can be eliminated, but they are still rejecting our advice, preferring instead to ensure the solvency of the private insurance industry.

John Goodman hides the rest of the story

Posted by on Thursday, Mar 19, 2009

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

The U.S. Health System: The Rest Of The Story

By John Goodman
Health Affairs Blog
March 19, 2009

Here is a paper (link below) with as many as 100 references that you almost never see cited in Health Affairs, or in the Journal of the American Medical Association (JAMA), or in the New England Journal of Medicine (at least not in their public policy articles). In fact, if you are a regular reader of these publications, I think you are going to be very surprised.

My colleagues Linda Gorman, Devon Herrick, Robert Sade and I discovered that public policy articles in the leading health journals (especially the health policy journals) tend to cite poorly done studies over and over again in support of two propositions: (1) Our health care system needs radical reform and (2) the reform needs to be modeled along the lines of the systems of other developed countries. At the same time, these articles tend to ignore contravening studies that are often published in economics journals and subject to much more rigorous peer review.

In our rest-of-the-story literature review, we focus on eight questions:

1. Does the United States spend too much on health care?

2. Are U.S. outcomes no better and in some respects worse than those of other nations?

3. Is the large number of uninsured in the U.S. a crisis?

4. Does lack of health insurance cause premature death?

5. Are medical bills causing bankruptcy?

6. Are administrative costs higher for private insurance than public insurance?

7. Are low-income families more disadvantaged in the U.S. system?

8. Can the free market work in health care?

John Goodman says that he wants us to hear the rest of the story, but then he doesn’t tell it to us.

He and his colleagues have pieced together a document using classic Goodman rhetorical deceptions. They pull out of the literature isolated items that support their position without identifying them as exceptions to the great body of information available in the health policy literature. They repeat the use of many studies that have been discredited as manipulations or distortions based on libertarian ideology, even though they are aware of the highly credible challenges to those reports. They use silly diversions to attack some of the most solid and important studies in the health policy literature. Patching these deceptions together creates magical conclusions that would seem to refute the most fundamental principles that can be gleaned from a couple of decades of solid health policy science research.

Using health policy reports retrieved from the refuse bin, they then end with the conclusion that we should adopt their favored proposal for reform, health savings accounts, a non sequitur to the specious arguments they have presented. Even though the policy community has dismissed HSAs as a serious response to the tragic dysfunction of our health care system and its financing mechanisms, the authors persist in abandoning their academic purity in pushing their cause.

“The Rest of the Story” might appeal to ideologues, but it is repulsive to those of us who are outraged by the the physical suffering and financial hardship faced by the millions of U.S. residents who are victims of a flawed financing system, unable to afford or receive the care that they need in a $2.5 trillion health care industry.

Paper on health care reform by John Goodman et al:

Tenet paid overtime hours by math, not money

Posted by on Wednesday, Mar 18, 2009

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

O.C. hospital owner to pay $85M to settle OT dispute

By Courtney Perkes
The Orange County Register
March 11, 2009

Tenet Healthcare, the owner of three Orange County hospitals, has agreed to pay $85 million to settle claims that nurses and other 12-hour-shift employees were denied extra pay after a change in California law entitled them to overtime.

At the time the law changed, Tenet was the county’s largest hospital owner with 10 facilities. In settling, the Texas-based company admitted no wrongdoing, but spokesman David Matthews said the California pay practice has stopped.

The case centered on Tenet’s “California differential” pay scale, according to court documents. The suit alleged that to avoid overtime costs, Tenet lowered the hourly pay rate for employees when they worked more than eight hours a day. That meant that while technically earning overtime, their net wages remained the same as before.

According to the suit, Tenet used as many as five hourly pay rates depending on the length of the work shift.

“It’s not enough for an employer to demonstrate that it pays overtime on paper,” said Frank Coughlin, a Santa Ana attorney representing Pagaduan. “They have to pay overtime in money, not math.”

Although PNHP is most noted for its advocacy of a single payer national health program, we also oppose the perversities of for-profit health care corporations in which the primary responsibility of the board of directors is to their investors. Tenet Healthcare has provided us with innumerable examples of these perversities. A quick Google of the PNHP website, in a fraction of a second, produced these lines and many more:

“For-profit hospital chain Tenet, formerly National Medical Enterprises (NME), is the subject of four separate federal investigations…”

“Troubled Tenet Healthcare dominates the expensive list…”

“Overall Tenet’s hospitals averaged gross markups of 477% over costs…”

“Last week, the hospital’s owner, Tenet Healthcare, agreed to pay $54 million to the government to resolve accusations that Redding Medical doctors conducted unnecessary heart procedures and operations on hundreds of healthy patients…”

“Tenet, the second largest US hospital firm, paid more than half a billion dollars to settle…”

“Tenet’s CEO exercised stock options worth $111 million…”

“OrNda Healthcorp, a hospital chain recently acquired by Tenet, paid fines of $12.65 million to the government for kickbacks to physicians for referrals…”

And this was only the first page Googled, but you get the gist.

Regardless of the wisdom of the California requirement of paying 4 hours of overtime for a 12 hour shift, it is the law, and there are several options that Tenet had to comply with it. As a for-profit corporation, they chose a method that would protect their investors from higher labor costs, but a method that involved dishonest accounting.

The employees no longer knew what their hourly wages were because, for each paycheck, Tenet retroactively calculated the hourly wage base so that it would wipe out overtime payments, and that base wage would vary from paycheck to paycheck.

Would you feel secure in a Tenet hospital? What other ways are they cheating to improve their bottom line?

HR 676, the United States National Health Care Act or the Expanded and Improved Medicare for All Act introduced by Rep. John Conyers, would provide for comprehensive health insurance coverage for all United States residents, but that is not all. Recognizing the conflicted interests of for-profit corporations in health care, HR 676 also includes the provision that for-profit providers of care opting to participate shall be required to convert to not-for-profit status.

HR 676 was introduced only seven weeks ago, and already has 66 cosponsors, far more than any other health reform legislation. Yet the members of the House and Senate who are leading the reform process have refused to include it in the dialogue on reform, insisting that any reform include not only the perversities of the for-profit health care corporations, but also, even worse, the profound waste and injustices of a financing system patched together with private health plans.

(The remainder of this message has been deleted because it contained expletives, or would have had it been written.)

SCHIP – a lesson on demographic incrementalism

Posted by on Tuesday, Mar 17, 2009

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

Beyond Incrementalism? SCHIP And The Politics Of Health Reform

by Jonathan B. Oberlander and Barbara Lyons
Health Affairs
March 17, 2009

Given the enormous political and fiscal barriers to adopting legislation that aims for universal or near-universal coverage, it could be tempting for Congress and the Obama administration to follow the expansion of children’s health insurance with further incremental measures. The political appeal of such a strategy is understandable: maximizing consensus on incremental policies while avoiding harder, more polarizing, and more expensive reforms is a time-tested strategy in U.S. health policy. Indeed, it is the exact political formula that produced SCHIP’s enactment in 1997. Advocates of incrementalism have long recognized that political constraints mean that the alternative to imperfect, limited reforms is, alas, often to do nothing. In that context, incrementalism looks quite appealing–a fallback position seemingly validated by the repeated failure of big-bang reform.

Yet there are real limits to incremental health reform. After all, despite gains in Medicaid and SCHIP, almost nine million children remain uninsured. The insurance system for children, notwithstanding their sympathetic status, is beset by the same problems that plague the rest of the U.S. health care system: fragmentation, inequality, and alarming coverage gaps. It is a sobering reminder of just how far the country has to go in health reform that we have not been able to secure universal coverage even for children.

There are also limits to a health reform strategy premised on demographic incrementalism that insures Americans group by group. Unlike children or the elderly, most uninsured Americans do not fit into sympathetic population subgroups that can be neatly matched to public programs. The SCHIP formula can only take us so far, since “all the ‘good’ (that is, politically attractive) populations are taken.” To make significant progress toward covering all Americans, we will have to adopt insurance expansions that don’t simply target politically attractive populations.

If the past decade has proved anything in American health policy, it is that incrementalism is not enough. A decade of incrementalism and inaction has left us with higher costs and rising numbers of uninsured Americans; absent decisive action, those trends will only worsen in coming years. It is encouraging, then, that both the Obama administration and key players in Congress are now pursuing bolder reforms. Perhaps we are entering a new era where U.S. health policy will finally move beyond incrementalism.

Incrementalism: the crossroads of policy and politics.

When each attempt at comprehensive reform fails, the usual response is for everyone to walk away. A few come back to try to retrieve whatever little bit that seems to be politically feasible.

The path of incrementalism has failed to slow the increase in costs and has resulted in increases in the numbers of uninsured and now greater increases in the underinsured. Lauding the mini-successes rings hollow when the health care system continues to have “fragmentation, inequality, and alarming coverage gaps.” By any reasonable standard, incrementalism has been a miserable policy failure.

The incrementalists tell us that the Children’s Health Insurance Program (CHIP) shows us that incrementalism can be a very successful approach to reform. There is no question that this program has been beneficial at least for those children covered. The primary detriment is that it reduced the political pressure for more comprehensive reform.

As the authors point out, children are perhaps the most attractive group for demographic incrementalism. It passes the test of politics, but fails on policy. The CHIP program that “covers all children” has left 9 million children without coverage, perpetuating “fragmentation, inequality, and alarming coverage gaps” for children! The very best incremental program that we have enacted in the past four decades has fallen far short of our goals for reform because beneficial policies were traded away in the politics of reform.

We are now at a rare moment in time when the politics seem aligned so that we can set aside incremental approaches for the time being and seriously consider comprehensive reform. The difficulty is that those leading the reform process are already abandoning important beneficial policies in what they believe will be a successful strategy to keep the politics aligned.

Let’s look at one important example. In their article, Oberlander and Lyons describe the fight over “crowd out,” the concept that, as you raise the qualifying income level for a government children’s insurance program, you increase the number of children that will move from private health plans to the public program that provides a better value. The qualifying income level is very problematic because it is middle-income families that have incomes too high to qualify for the program yet too low to readily afford private insurance. Although the opposition to crowd out could be perceived as an attempt to protect the private insurance industry, the policy principle is much more fundamental.

As the authors explain, “The SCHIP debate revolved around the same boundary issues that will determine the fate of comprehensive reform in 2009 and beyond: the balance between public and private insurance, who should be eligible for government subsidies and at what income level, whether health care is an individual responsibility or social good. Those issues are far from resolved.”

So… the intersection of policy and politics. Those who are leading the reform process and who should believe that health care is a social good are supporting policies that will leave the private insurers in charge, invoking the politics of appeasement to satisfy those who believe that health care is an individual responsibility.

If we are going to achieve our goals of affordable, high quality health care for everyone, it is absolutely imperative that we adopt policies that advance health care as a social good. Policies that shift the responsibility to the individual will further increase our problems with fragmentation, inequality, and alarming coverage gaps.

Whether following a path of incrementalism or the enactment of comprehensive reform, this political divide will never go away. Appeasement politics will always be ruinous for the social good of health care.

The bottom line: The politics must support the policies of health care as a social good, with no compromise. The battle must continue until it is successfully executed. Perceptions of defeat are only perceptions. That is not the time to walk away and eventually crawl back on the ragged path of incrementalism. We must continue the charge, no matter the battle scars, until we achieve health care justice for all. Our finances, our health, and our lives depend on it.

Health insurance and eye care

Posted by on Monday, Mar 16, 2009

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

Reported Eye Care Utilization and Health Insurance Status Among US Adults

By David J. Lee, PhD; Byron L. Lam, MD; Sahel Arora, BS; Kristopher L. Arheart, EdD; Kathryn E. McCollister, PhD; D. Diane Zheng, MS; Sharon L. Christ, MS; Evelyn P. Davila, MPH
Archives of Ophthalmology
March 2009

The association between low eye care utilization rates and lack of, or inconsistent, health insurance coverage, even after adjustment for income and educational attainment, suggests that overall ocular health care access would be enhanced if progress is made toward securing coverage for the 46.6 million Americans who do not currently have health insurance. Our findings have also identified troubling gaps in eye care utilization among adults with health insurance coverage. Adults who reported an interruption in health insurance coverage in the 12 months prior to the interview were less likely to report a visit to an ocular health care provider than were those who were consistently insured. In our analyses, 3.8% or an estimated 7.8 million US community-residing adults annually reported such a coverage gap in the past 12 months.

We also found that adults who reported concurrent private and public health care coverage were generally more likely to report an ocular health care visit in the preceding 12 months than were adults who had private insurance only, even after adjustment for level of visual impairment, sex, and educational attainment. The NHIS (National Health Interview Survey) did not assess whether ocular care was included as part of the participants’ insurance coverage. It is nevertheless possible that public coverage filled in some of the well-known gaps in ocular health care coverage of many of the private health care plans offered in the United States. For example, Medicare and Medicaid typically include basic eye care services, such as annual eye examinations. Our findings point to the need for addressing the coverage limitations for ocular care in private insurance plans as well as addressing the broader need for health insurance for all Americans.


Is Universal Vision Care Coverage the Best Way to Get People to See Their Eye Care Providers?

By Steven M. Kymes, PhD, MHA; Kevin D. Frick, PhD
Archives of Ophthalmology
March, 2009

In this issue of Archives, Lee et al present a report on the relationship between insurance coverage and recommended visits to ophthalmologists or optometrists. They find several important predictors of such visits, one of which is health insurance coverage. In their conclusion, they call upon vision care professionals to assume a role as advocates for universal health insurance coverage, in particular vision care insurance, for all Americans. They assert that providing universal vision care coverage would insure that financial resources are no longer a barrier for those seeking access to a vision care provider. However, we must also consider whether this would indeed be the most effective method to achieve the social goal of increased use of vision care services.

It is important to recognize that if we as a society provide universal health insurance coverage, it would not come without a cost.

(The authors then provide a highly dubious analysis that purports to show that “our health care system would pay $435 in annual insurance coverage for each new person who is motivated to seek vision care.”)

There is no doubt that providing preventive vision care services is important, as is providing care for those with chronic eye conditions. But before taking this step, we should ask if the benefit of spending $435 to motivate someone to seek an annual visit to their eye care provider outweighs the cost. Answering the question would involve a rigorous evaluation of the benefits of the ocular examination. What is the probability that an undiagnosed ocular condition will be found? What is the benefit of identifying that condition in reducing future health care costs? What is the benefit of regular examinations of people with chronic eye conditions in adjusting treatment strategies, insuring compliance, and making referrals for specialized care? By asking such questions, we can determine the balance between costs and benefits. The results would help policymakers and physicians to determine if providing insurance coverage would indeed be the best approach to promoting vision care or if other methods of improving access should be considered.

Lee and colleagues have made an important contribution to this growing literature by examining barriers to vision care. However, the principles of scientific inquiry should not be shortchanged simply because we are debating a policy question rather than a biochemical one. The vision care community has an obligation to fully consider alternative solutions and their consequences in seeking ways to remove barriers to vision care.

One single word, whether it’s “and” or “or,” can make such a difference in health policy.

This study confirms that what we already know about the importance of insurance in improving access and utilization of health care also applies specifically to eye care. Individuals with insurance have higher rates of access and utilization of eye care than those who are uninsured and those have have interruptions of their insurance coverage.

This study also indicates that those who have public coverage in addition to private coverage have significantly higher utilization rates than those who have private coverage alone. Public coverage seems to help fill in the gaps in private coverage.

The obvious policy conclusion is that everyone should be covered with health insurance that has adequate benefits, including eye care. Quite simple.

Apparently that is not the conclusion of the authors of the commentary on this study that appears in the same issue of Archives of Ophthalmology, a publication of the American Medical Association. To improve access to vision care, they do not suggest removing one of the more important barriers to care by providing everyone with health insurance. Without stating it explicitly, they imply that their estimate of a $435 premium (a straw man estimate) is too high of a price to pay for eye coverage. Instead they recommend the consideration of insurance coverage “or” the consideration of other methods of improving access. There is that all important “or” word, when most members of the policy community would have used “and.”

Just to indicate that this wasn’t simply a slip of words, they reinforce their view by stating that “the vision care community has an obligation to fully consider alternative solutions,” where “alternative” is another “or” word.

This study is a valuable contribution to the health policy literature, indicating, once again, that we must repair our health care financing system so that everyone has affordable access to all necessary health care. It is sad that there are those who continue to use garbage policy pseudo-science to battle the champions of health care justice. And it is especially tragic that they have continued to win.

President Bill Clinton on single payer

Posted by on Friday, Mar 13, 2009

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

Bill Clinton on Health Care Reform

CNN Larry King Live
March 11, 2009

Dr. Sanjay Gupta, CNN chief medical correspondent: Tonight, Bill Clinton exclusive on the nightmare that keeps 45 million Americans from seeing a doctor — the health care disaster.


GUPTA: All right. Let’s drill down specifically on something you said earlier. When it comes to sort of creating these silos of health care reform — you have sort of single payers and more governmental involvement on one send — one end, free market involvement solely on the other end. Single payer never has really caught traction politically. Is it politically unpalatable or is it a bad idea?

Bill CLINTON: Well, I think it’s more politically unpalatable than it is a bad idea, because single payer is not socialized medicine. Canada has a single payer system and a private health care provider system. Our single payer systems are Medicare and Medicaid.

GUPTA: Sure.

CLINTON: And Medicare is quite popular.

The good thing about single payer is the administrative costs are quite low. We probably waste $200 billion a year between the insurance administrative costs, the doctors and other health care providers’ administrative costs and employers’ administrative costs in health care that we would not waste if we had any other country’s system.

On the other hand, if you look at the experience of Germany, France, Japan — that don’t have pure single payer systems, they have more mixed systems — their costs are actually slightly lower overall than Canada’s. So there’s something to be said for having a mixed system if you can get the administrative costs down, because then the systems have enough competition in them to try to restrain costs and it’s not all up to the political bodies.

In Canada, because it’s all financed through the government, it’s more difficult sometimes for the politicians to say no than for just the regular management of the health care system to cut the costs.

So I think you can have a mixed system. If you look at the French system, which scores very high on every international measure…


CLINTON: …it’s mostly publicly financed, but there’s enough private in there that there’s some tension that’s creative and positive.

GUPTA: Do you think there is a degradation quality of care with a single payer system? Is that a concern? Should that be a concern?

CLINTON: Well there’s no evidence of that in Canada that I’m aware of, except for excessive delays, which they always try to come to grips with. The British, you know, do have a completely government-run system, but they allow people who can afford it to get outside the system. And they’ve also started running hospitals almost like charter schools in America, that is, they have these trust hospitals that perform very well and therefore they’re given more control over setting their priorities, specializing and cutting delays.

There are all kinds of different ways to do it. But first, you do have to cover everybody. And then you have to stop people from gaming the system. There’s a lot of gaming going on now in the American system so that we spend more than anybody else and get loss for it.

I think that once you get the universal coverage, I think the health insurers then could play a more positive role than they do now, which is often involved in — you know, they make a lot of money through saying no and sort of the inordinate paperwork burdens that are put on doctors and hospitals and other providers.

GUPTA: What is it about the insurance industry that you just brought up? They tried to scuttle the health care reform plan of ’93. Now they’re saying we also believe in universal health care. A politically tactile question, I guess, are you buying it? Do you think they’re being honest?

CLINTON: I think some of them really do want it. Yes. If you look at their new organization, the person who heads it came out of a progressive background and favored, as a philosophical matter, coverage.

Secondly, I think they now understand that, in terms of the health of America and the well-being of our economy, we can’t go on basically giving them more and more dollars every year — the insurance industry — and getting people sicker and sicker and leaving more and more people behind.

I mean look at all the healthcare problems. The child obesity problem, which is my obsession, is the most glaring manifestation of a system that treats sick people and doesn’t keep people well. And that’s one where, I think, by the way, we can get broad bipartisan support on trying to — to do more on wellness. And that will save money.

I think the insurance industry realizes that they — a lot of the smarter ones realize that they could kill the goose that laid the golden egg here, that America can no longer go on spending more money and getting less for it and having all this money go to them and that they can make a lot of money and do well by making us healthier at a more affordable price.

Former President Bill Clinton makes two very important points here. (1) Single payer dramatically reduces administrative waste, and he implies that it would be popular, as is Medicare now. (2) The private insurers “make a lot of money through saying no,” and “we can’t go on basically giving them more and more dollars every year — the insurance industry — and getting people sicker and sicker and leaving more and more people behind.” Single payer is good; private insurers are bad.

In contrast, his comments suggesting that private insurers could play a beneficial role in a system of universal coverage are not supported by the facts.

He says that private plans in other nations provide competition which helps to lower costs below that of Canada. Wrong. First, our experience with the Medicare Advantage plans demonstrates that competing private plans increase costs instead of decreasing them. Second, there are many factors that influence health care spending besides the structure of the financing system.

According to the OECD, “Whatever the role played in a health system, private health insurance has added to total health expenditure.” According to the WHO, “Evidence shows that private sources of health care funding are often regressive and present financial barriers to access. They contribute little to efforts to contain costs and may actually encourage cost inflation.” Spending in the nations cited by President Clinton would be even lower if they had a pure single payer system. (qotd 8/21/07)

As for his optimism for a beneficial role of private insurers in our future, he had to take that one from his wish list. It’s been on all of our wish lists for decades. Isn’t it time to quit wishing, accept the fact that they’re incorrigible, and move on with our own single payer national health program?

The White House Press Secretary, late last week, had this exchange with a venerable member of the press corps:

Helen Thomas: Why is the President against single-payer?

Robert Gibbs: The President doesn’t believe that’s the best way to achieve the goal of cutting costs and increasing access.

Early this week President Obama, in remarks on the occasion of his reversal of the Bush Administration ban on embryonic stem cell research:

President Obama: Promoting science isn’t just about providing resources — it’s also about protecting free and open inquiry. It’s about letting scientists like those who are here today do their jobs, free from manipulation or coercion, and listening to what they tell us, even when it’s inconvenient — especially when it’s inconvenient. It is about ensuring that scientific data is never distorted or concealed to serve a political agenda — and that we make scientific decisions based on facts, not ideology. (Applause.)

When health policy researchers do their jobs, free from manipulation or coercion, they reveal a fact that many in Congress find especially inconvenient: private health insurance companies subtract enormous resources, and add nothing, when it comes to the care of patients. Single payer national health insurance will not only cut hundreds of billions of dollars in health costs annually but increase access more than any other proposal — it will include everyone.

The President and the Congress have launched a public discussion of health reform, in regional White House forums hosted by Governors, and also in congressional committees.

Mr. President: will you listen to the science, hear the facts — and rediscover single payer?

Attention Congress: our nation deserves a fair hearing of the evidence. Will you allow a comparison of single payer with every other proposal, in every committee of jurisdiction?

It is time for health reform based upon health policy science.

Blog debate – PNHP versus HCAN reform strategy

Posted by on Thursday, Mar 12, 2009

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

Blog Debate: “An Obsolete Model”

By Tim Foley
Health Care
March 12, 2009

This is the second day of a blog debate about what approach we should take on health care reform in 2009. Debaters are Dr. Don McCanne, a retired family physician now serving as Senior Health Policy Fellow for Physicians for a National Health Program, and Jason Rosenbaum, a writer and activist, and the Deputy Director of Online Campaigns for Health Care for America Now! Dr. McCanne will be presenting the “single-payer” point of view, and Mr. Rosenbaum will be presenting the “public competitor” point of view.

This is Dr. McCanne’s answer to the question: Is there anything valuable that private insurance brings to the table which, with far more muscular federal regulation, would enhance an American universal health care system?

Dr. McCanne: Everyone agrees that we need comprehensive reform of health care financing if we expect to slow the escalation of costs, while improving allocation of our resources. To achieve these goals, do we need to replace our dysfunctional financing system with an efficient public program, or can we simply use increased regulatory oversight to transform our private insurers into a better functioning system?

Systems using private plans that achieve near-universal coverage, such as Switzerland and Holland, are often cited as examples that we can emulate. These systems are more expensive, with greater administrative complexity, less equity, and fall short of true universality, though they satisfy those who ideologically prefer private to public administration. Some nations also use public programs for low-income individuals, comparable, in principle, to Medicaid in the United States. So how would it work if we were to regulate the private plans and then mandate the purchase of those plans?

There is a very fundamental difference between our private plans and theirs. Other nations that use private plans do so within a program of social insurance. Their plans are designed for the public good, assisting individuals in receiving the care they need without having to be concerned about the source of payment. They fulfill the insurance function by effectively pooling risks, whether through a single risk pool or though various methods of risk adjustment.

Our private plans are based on a business model designed to ensure success in the health care marketplace. Success is defined by the medical loss ratio, spending the least they can on health care. Much of their profound administrative waste is due to their elaborate efforts to avoid paying for care.

The plethora of private plans merely demonstrates the insurers’ innovations in restricting benefits — preventing payment for non-covered services; increasing deductibles and other forms of cost sharing — erecting financial barriers to care; contracting with limited lists of providers — penalizing patients who need care outside of the restricted lists; selective marketing to healthy populations — especially the healthy workforce and their young, healthy families; using underwriting and rescissions to avoid paying for essential care; and on and on. These are great business tools, ensuring success of the insurers, but they are anathema to the more egalitarian goals of social insurance systems. They defeat the insurance function of pooling risk by segregating out the low-cost healthy into their own market, and dumping the high-cost sick onto taxpayer funded programs.

Suppose we heavily regulate our private insurers and require guaranteed issue of plans that actually include all necessary services, and remove barriers to care such as restrictive lists of providers and unaffordable deductibles. This would require a massive, revolutionary transformation of the missions, goals, and administrative functions of our business-model private plans designed to prevent paying for care, into social insurance private plans designed to remove the financial system as a barrier to care.

Anyone who believes that this would be a simple transformation needs to have a conversation with insurance executives with their nine-figure compensation packages or with the large institutional investors who have fared extremely well under our market-based health care financing system.

As if that weren’t enough, there is one more unique problem in the United States. Our health care costs are much higher than in any other nation. If we were effective in covering everyone with a choice of private plans, whether with or without a public option, and if those plans covered the necessary care that people actually need, imagine the premium that would have to be charged.

The Milliman Medical Index has demonstrated that an average family of four with employer-sponsored coverage — a healthy sector — already pays $15,600 for their health care. That is only average; many pay more. With a typical household income of $60,000, that is no longer affordable. Now add into the pool the less healthy members of our population and just imagine what the premium would have to be. Financing our health care system through a specific premium assigned to an individual or family, based on an adequate package of benefits, has become an obsolete model of paying for health care.

We need a single, universal risk pool that is equitably funded. That would most easily be accomplished through progressive taxes. Once we do that, why would we continue to support the intrusion of the wasteful private insurers that do no more than take away our choice of hospitals, physicians and other professionals? Public administration is much more efficient, plus enrollment is a one-time event — absolutely everyone is covered for life.

For the full debate (in progress):

Members of Physicians for a National Health Program (PNHP) and supporters of the Health Care for America Now! coalition (HCAN) are all passionately dedicated to the goal of achieving reform that will provide affordable, high quality care for everyone. We are bothers and sisters in the cause. The ultimate goals of both organizations are the same, but the strategies are quite different.

The PNHP single payer concept has been around for a couple of decades, but Congress has failed to move on it. The HCAN leadership decided that reform will never occur unless the private insurance industry plays a major role in the future of health care financing, but that the insurers must be challenged with a competing, public Medicare-like option. In theory, the public option would be a better value, and the private plans would fade away as individuals opt to change to the new Medicare program.

There is massive, intense opposition to the public option by the same elements that have been successful in defeating reform in the past. AHIP, PhRMA, the U.S. Chamber of Commerce, the Republican members of Congress, and many others are all opposed to the Medicare-like option.

If the final legislation includes a well-designed public option (adequate benefit package, truly affordable premiums, no excessive cost sharing, the use of private insurer funds for risk adjustment, etc.) then there will be no comprehensive reform. The opponents are powerful enough to defeat it.

If the final legislation includes an emasculated public option, or leaves it out altogether, then reform will be based on a market of private plans.

Following the HCAN strategy, it is absolutely inevitable that private plans will continue to play a major role in financing health care, whether or not comprehensive reform is enacted. The reason that I selected my response on private insurance from our PNHP/HCAN blog debate is that everyone has to understand very clearly why private health plans are an obsolete method of financing an expensive health care system like we have in the United States. Once everyone understands that, we can reject the HCAN strategy and move forward with the program America needs: a single payer national health program.

You are encouraged to follow the debate this week (only four questions) and provide your comments ( Tim, Jason and I are very interested in your thoughts, and hopefully the policymakers will be as well.

Bloomberg columnist on single payer

Posted by on Wednesday, Mar 11, 2009

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

No Reason to Demonize U.S. Single-Payer Health

Commentary by John F. Wasik
March 11, 2009

It’s time to stop kicking sand in the face of single-payer health care. It may be the strongest solution around to insure every American at a lower cost.

After decades of industry campaigns against this model — dubbed by its critics as “socialized” medicine — it’s important to stop whining and evaluate the many economic benefits. Health care is a fundamental human right.

If President Barack Obama wants real change in American health care, he will have to get over the fear of even mentioning single-payer concepts. At his health-care summit last week, only the threat of a demonstration garnered late invitations for Oliver Fein and Congressman John Conyers, two leading proponents of the single-payer plan.

Health-care costs have become a crippling personal-finance burden for 45 million uninsured and 25 million underinsured Americans. Those outside of the fractured employer-based system are only one illness away from financial ruin.

Lose your job and most likely your health coverage will disappear unless you want to pay exorbitant rates. And it’s getting worse. Because of the growing jobless rate, some 14,000 Americans are losing their coverage daily, according to the Center for American Progress Action Fund.

A single-payer plan would cover everybody regardless of employment situation and save money by cutting out middlemen.

(John F. Wasik, co-author of “iMoney,” is a Bloomberg News columnist. The opinions expressed are his own.)

Single payer should not only be back in the national dialogue on reform, it should be front and center as the golden standard by which all other options are compared.

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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.

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