News

Theodore R. Marmor, Ph.D., Professor of Public Policy & Management and Professor of Political Science, Yale University School of Management, and author, "The Politics of Medicare," responds to AMA's resolution supporting balance billing of Medicare patients:

Interesting example of regression to 1966 position, with the effort to use the misery of managed care as a rationale. There is no connection between whatever misery managed care has brought and the old dispute about balance billing. Doctors understandably would like to charge whatever they can; it just so happens that financial freedom, professional autonomy, and widespread health insurance are together practically impossible. Sad to see so little learning.

Ted

Posted by pnhp at 05:04 PM | Permalink | Comments (0)

American Medical Association House of Delegates
Resolution: 713

Subject: Measures for the Return of Physician Financial Freedom

Whereas, The past fifteen years have seen the introduction of managed care and inequitable changes in Medicare reimbursement which has been a failure in reducing the rapid rise of medical costs; and

Whereas, Physician reimbursement is less than 20% of total medical expenditures and the time has come to end this miserable experiment and stop unilateral wage control; therefore be it

RESOLVED, That our American Medical Association work to implement the following:

1. Physicians be allowed to balance bill Medicare recipients to the full amount of their normal charge with the patient responsible for the difference between Medicare allowable and physician charges; and

2. Managed Care Organizations be banned from using Medicare reimbursement rates as a basis for their reimbursement and that reimbursement for 2003 should be at least 200% of the usual, customary, and reasonable fee of 1988; and be it further

RESOLVED, That our AMA seek introduction of national legislation to bring about implementation of balance billing of Medicare recipients.

Fiscal Note: No Significant Fiscal Impact

http://www.ama-assn.org/ama1/upload/mm/interim02/j713i02.rtf

Comment: The House of Delegates of the American Medical Association passed this resolution at their meeting in New Orleans in December 2002.

Arthur Traugott, M.D., an Illinois delegate, in the debate preceding the approval of this resolution:

"If we're going to look at it only from the physician side, we'll have a bad PR image problem."

http://www.ama-assn.org/sci-pubs/amnews/pick_03/gvsb0106.htm

Posted by pnhp at 12:04 PM | Permalink | Comments (1)

USA Today
12/30/02
Health care is in 'dire need' of remedies
By Susan Page

Gore, who announced this month that he won't run for president in 2004, still plans to deliver a speech early next year outlining his proposal for a government-financed program that ensures health care for everyone. The so-called single-payer system is often called a "Canadian-style" plan; Gore says his version will be distinctly American. Associates say his proposal will offer a choice of plans that would be administered by private insurance companies, not the government.

http://www.usatoday.com/news/health/2002-12-29-health-care-usat_x.htm

Comment: Gore's proposal to offer a "choice of plans" suggests that he will fail to address the problems of cost shifting, adverse selection, tiering of benefits, financial barriers of cost sharing, and other flawed policies that plague our current system. Continuing with these policies and including private insurance companies as a major player also fails to utilize one of the most important advantages of a single payer approach: eliminating the waste of the administrative excesses of today's system.

95% of Americans want something done about health care costs. Gore's plan would do that if we were to regulate private plans by requiring mandated benefits, price controls, a "national" community rating, severe restriction of administrative spending, and other measures that might characterize a single payer system. But then, what insurance company would participate in such a system? Only our own publicly administered system could function within a set of rules that would require equity, efficiency, accessibility, comprehensiveness, portability, affordability, and other features assured by a single payer system.

Let's end the games and get on with real reform. Ronald Brownstein's words
express the urgency of the problem (Los Angeles Times, 12/30/02):
"More families without care, longer lines in emergency rooms, more hospitals
and public clinics bleeding red ink, more kids sick at school: That's what is looming if Washington continues to close its ears to the health-care alarm ringing now in California -- and soon in state capitals from coast to coast."

http://www.latimes.com/news/nationworld/nation/la-na-utlook30dec30,0,494996
6.column?coll=la%2Dheadlines%2Dnation%2Dmanual

Posted by pnhp at 11:57 AM | Permalink | Comments (0)

Elinor Christiansen, M.D., President of the American Medical Women's Association, responds to Professor Uwe Reinhardt's comments on the health
care system in mainland China:

I believe Uwe Reinhardt is mistaken in his statement that "the Communist Peoples Republic of China on the mainland has a basically capitalist health system with millions of uninsured, among them all children."

The Communist Peoples Republic of China has provided free health care, including immunization and birth control, to everyone living in their country through government assigned clinics for forty years. Their public health achievements have been remarkable with eradication of epidemic diseases such as tuberculosis, malaria, yellow fever, liver fluke and other intestinal parasites, tetanus (which used to be the major cause of infant mortality prior to communism), and sexually transmitted diseases. Unfortunately sexually transmitted diseases and other infectious diseases had crept back into mainland China with opening its doors to the outside world.

Also unfortunately many of the government clinics, especially in rural regions, are staffed by "barefoot doctors" who are persons with minimal education and limited medical training, perhaps similar to a nurses aide, or in some cases an EMT. Some of the government clinics provide only traditional Chinese medicine, whereas others provide Western medicine (usually in urban areas), and some clinics provide both traditional and Western medicine (also usually in urban areas).

Hospitals are exceedingly well staffed with an abundance of well-trained physicians and registered nurses who are often housed in high rise residences on the hospital grounds. Quality burn care, reattachment of traumatic amputations, and organ transplants are done in hospitals in all the major cities with excellent outcomes. And the entire cost is paid by the government. Physicians, nurses and other health care workers are salaried by the government.

Recently, since the Tien An Men episode, retired physicians have been allowed to open private offices to see private patients on a fee for service basis (very modest cost). This recently permitted alternative allows patients (parents and their children who do not want to wait to be seen in the public clinics to which they are assigned a convenient alternative at their own expense.

I do not know Uwe's source of information or misinformation, but if Uwe or anyone else wants to know more about the universal health care which has been in place in mainland China for probably five decades they may contact me.

Elinor Christiansen, MD

R. Covell on health care in mainland China

Ruth M. Covell, M.D., Associate Dean, University of California at San Diego
School of Medicine, responds to Elinor Christiansen, M.D. on health care in
China:

Elinor and I must have been in a different country (5 years ago)....I
experienced good physicians but 1930s equipment, record keeping, technology
etc. in several medical school hospitals.

Elinor and I must have been in a different country (5 years ago)....I
experienced good physicians but 1930s equipment, record keeping, technology
etc. in several medical school hospitals.

Uwe Reinhardt responds to Elinor Christiansen's comments on health care in mainland China:

We recently visited China and spoke with people both in major medical centers and in the Ministries of Social Affairs and of Health. None of them would agree with Dr. Christiansen. The rural health system has all but collapsed, we were told. The urban system is now run on a fee for service system, leaving out many uninsured altogether. Employed persons usually receive health insurance on the job, but it does not cover their children. That is what we were told.

The system Dr. Christiansen describes would not be recognized by the people we contacted and spoke to.

Posted by pnhp at 03:18 PM | Permalink | Comments (0)

Alliance for Health Reform
12/16/02
Employer Coverage: Mounting Challenges, New Approaches

An Update on Employer-Based Health Insurance
Jon R. Gabel, Vice President, Health Research and Educational Trust

Final slide of his presentation:

The Immediate Future - More of the Same
. Double-digit increases in premiums
. A soft economy will make employees more vulnerable to rising costs
. Increased employee contributions, copays, deductibles and coinsurance
. Heavily managed care as a niche product
. Consumer-driven care as a niche product
. More uninsured Americans

http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=736

Posted by pnhp at 03:20 PM | Permalink | Comments (0)

Dec 27, 2002
Frist Will Not Help Health Care's Ills
by Jamie Court & Frank Smith
 
This article appeared in the San Diego Union Tribune on December 26th: by Jamie Court and Frank Smith

Capitol Hill's well-heeled lobbyists and political cognoscente have proclaimed that with a doctor in charge of the U.S. Senate, health-care reform is imminent. Unfortunately for the public, the doctor running the chamber, Sen. Bill Frist, typifies the GOP's new health-care strategy: care most about the health of corporations that elect you.

If the public does not stop Frist and K Street's hired guns, the gains of the patients' rights movement will be erased and the freedoms of drug companies, HMOs and hospital chains will be expanded at the expense of patients.

A heart and lung surgeon, Frist sponsored legislation this year limiting legal liability for drug-maker Eli Lilly and other manufacturers of a mercury-based additive to vaccines that is linked to autism in children.

The provision drew outrage from parents of autistic children as special-interest pandering when it passed as part of the Homeland Security legislation just after the election. The corporate pork was the first payback for pharmaceutical companies' heavy last-minute financing for key Republican Senate candidates that changed the balance of power in the Senate. The Washington Post also reported recently that Eli Lilly bought 5,000 all copies of Senator Frist's recent book.

As head of the National Republican Senatorial Campaign, Frist raised more than $100 million for GOP senators' election campaigns. It is in this fund-raising role that observers say Frist won his new post. In 2003, the debts to these donors, many from the medical-insurance complex, will come due. As Senate majority leader, Frist will have the power to schedule or not schedule votes on legislation, determine committee assignments and control all debate, absent a super majority against him. (Given these powers, it is little wonder there were few words of criticism about his election even from Senate Democrats.)

Frist's ownership of and entanglement with one of America's biggest corporate criminals, hospital chain Columbia/HCA, shows where his loyalty is and should have prevented him from leading the U.S. Senate. In total, the company, now called HCA, will pay more than $1.7 billion in civil and criminal penalties - the largest amount ever in a health-care fraud case.

Frist's family founded the company, which the government prosecuted for massive billing fraud. USA Today reported that U.S. Senate disclosure statements show he owned as much as $25 million in company stock. His wife has more than $1 million in stock. Frist claims the money is in a blind trust, but when a trust is invested heavily in a company, rather than an industry, it is all too visible. Rep. Pete Stark, the senior Democrat on the Ways and Means health subcommittee, recently stated that the government's HCA settlement may have understated the fraud and could benefit the Frist family greatly. If Frist was a patriot, he would have sold his HCA stock a long time ago.

In the Senate, Frist has used this influence to further HCA's interests by successfully blocking a strong patients' bill of rights, gridlocking a mandatory Medicare prescription drug benefit, and promoting arbitrary caps on legal recovery by innocent victims who sue negligent hospitals like HCA.

With the heart and lung surgeon in charge, a whole new set of "health care" issues are likely to make the Senate tick.

- Patients' rights

Instead of expanding patients' new rights to hold HMOs legally accountable for delaying or denying care, the Senate debate will now be about limiting the rights of innocent victims of medical delays and negligence to hold accountable doctors, hospitals and the HMOs they work for.

- Medicare prescription benefit

Rather than force price controls on a pharmaceutical industry that turned the tide for the GOP, the Senate will create a "voluntary" prescription drug program with insurers selling a new product to seniors with new profits.

- Universal coverage

Forget a national Medicare plan for everyone who needs affordable health coverage. The Senate will focus on Medical Savings Accounts (MSAs) which force the public, instead of insurers, to pay for their health care; bare-bones insurance policies that do not pay for drugs, hospitalization or maternity costs; and mandatory insurance laws that force people to buy an unaffordable, low-quality product.

Watch out, America. If the public does not lash out, health-care reform will be about new burdens on patients and new freedoms for industries.
Court and Smith are co-authors of "Making a Killing: HMOs and the Threat to Your Health" (Common Courage Press). Court is executive director of the Foundation for Taxpayer and Consumer Rights. Smith is a senior fellow at Civil Society Institute.

Posted by pnhp at 04:35 PM | Permalink | Comments (0)

Lawmaker by day, good Samaritan by night, Sen. Bill Frist (R-Tenn.) is a wealthy doctor-turned-politician who occasionally attends art openings at his family-endowed museum-but prefers to spend his vacations visiting remote African villages to dispense lifesaving care.

It goes without saying that he pilots his own plane.

So Frist fits neatly into the melodramatic script of Trent Lott's fall from power, cast as the new majority leader called on to rescue the party in a moment of peril. "He really shows the true compassionate conservatism," says Sen. Kay Bailey Hutchison (R-Tex.).

But this plot twist raises a thorny question that only time will answer: Can those delicate surgeon's fingers manage the backslapping, arm-twisting, hand-holding and pocket-picking that comprise the sometimes grubby backroom reality of a Senate leader's life?

His supporters point to the bills Frist has co-sponsored with politicians as wily and seasoned as Sen. Edward M. Kennedy (D-Mass.), and to his acclaimed leadership of the National Republican Senatorial Committee, where he captained the recent campaign to regain the Senate majority.

They also acknowledge that Frist's background-well-born, expensively educated and drawn to the notoriously independent life of the superstar surgeon-was not an obvious preparation for his new life of haggling and dealmaking. "There are a lot of key senators who don't really think they need any leadership," a Capitol Hill veteran said. "Leadership is not a problem in the Senate. Followership is."

The expertise that has made Frist an effective force in health care legislation will become relevant in a smaller-though still important-segment of his life. The close working relationship he has forged with President Bush will be, at least initially, viewed with some suspicion by senators who resent the role the White House is perceived to have played in Lott's demise. And the idealism that Frist says motivated him to run for the Senate in 1994 will be a difficult candle to keep burning when the winds of political expedience start gusting.

Frist spoke of the difficult balance between nitty-gritty politics and a Dr. Kildare idealism in a recent Boston Globe interview. "There is this tension between two forces I am engaged in, between raw political power versus . . . the real quest, the real drive for substantive issues." It is a tension that will only grow.

William F. Frist, 50, is the son of a Tennessee legend, the late Thomas H. Frist, physician to six governors and founder of the Hospital Corporation of America, now known as HCA. The future senator grew up in Nashville's wine-sipping GOP precinct Belle Meade, an exclusive suburb, and went to school at the elite, all-boys Montgomery Bell Academy before heading off to Princeton and then to Harvard Medical School. He was a daredevil lad, speeding on motorcycles at 15 and making his first solo flight a year after that.

Though Frist invested from an early age in HCA stock-the basis of his multimillion-dollar fortune-he decided that he would never play a role in the company that his father and brother, Thomas Frist Jr., built into the largest chain of for-profit hospitals in the country. Instead, Frist threw himself with consuming intensity into becoming a transplant surgeon. In an episode that he now says he deeply regrets, Frist toured animal shelters around Boston, offering to care for stray cats that he then killed for medical experiments.

"Medical school," he wrote, "was in the business of stripping human beings of everything but the raw, almost insane, ambition you must have simply to get through."

Frist's background was Southern, but not Deep South. Nashville was home to an established black middle class and a thriving Jewish community. By living in New Jersey, Boston and Northern California, Frist became a cosmopolitan member of the American wealthy elite. It suggesting that he may have more in common with the last majority leader from Tennessee-Howard Baker-than with the two more recent GOP leaders, hardscrabble Kansan Robert J. Dole or Lott, the son of a Pascagoula shipyard worker.

After his training, Frist returned to Nashville to practice at Vanderbilt University's well-respected hospital-again avoiding the family chain. He specialized in transplant work, heart and lung replacements, sometimes flying his plane to retrieve an organ, then rushing it back for installation.

The distance he maintained from HCA probably saved his political life.

In the late 1980s, the Frist family company was swallowed in a hostile takeover, and Frist's father and brother ceded management control to the owners of what became Columbia/HCA. In 1997, FBI raids on company hospitals turned up widespread Medicare fraud. According to attorneys for the whistleblowers who revealed the massive overbilling, HCA engaged in illegal practices even before the takeover. But Thomas Frist Jr. returned to the helm of the company as unpaid chairman and chief executive, and worked to restore trust in the company.

This week, HCA (the old name is back) announced that it would pay the federal government $631 million to settle fraud claims-bringing the total payments by the company to $1.7 billion.

When Frist challenged Sen. James Sasser (D-Tenn.) in 1994, he disclosed that $13 million of his $20 million in assets was in HCA stock. Much of his wealth, and that of his wife and three sons, is in limited blind trusts with a value of between $10 million and $35 million, according to his 2001 financial disclosure report.

But this distance from HCA has not entirely shielded Frist from attack. "With the health system in crisis, Republicans are considering a Senate majority leader who made his millions from a family-run company that defrauded Medicare, overstated expense statements, billed for services ineligible for reimbursements and paid kickbacks to physicians to encourage referrals to HCA facilities," said Physicians for a National Health Program, which has clashed with Frist over health care issues.

Spending $3.7 million of his own money, Frist capitalized on the Republican tide of 1994 to crush Sasser by 14 percentage points. In the eight years since then, he has personified the Bush administration dream of conservatism with a friendly face. Frist is "part of the conservative core of the caucus," a leading Republican said yesterday, "but stylistically he is cool; he has a different set of credentials and a more bipartisan, moderate demeanor than a lot of people with identical voting records." Frist has voted with Lott, for example, more than 90 percent of the time.

Being the first physician elected to the Senate in more than 50 years is a big part of that. Republicans have played up his medical expertise, drawing credibility from Frist's medical degree on such key issues as patients' rights, Medicare and prescription drug benefits. "Dr. Bill Frist" is the preferred mode of address for Bush and Senate colleagues. Party leaders get dreamy-eyed when they picture the new majority leader saving a life on the Capitol grounds-as Frist has done a couple of times in the past eight years. (Once, he resuscitated a collapsed tourist; another time, he tended to the grievously wounded gunman who killed two Capitol police officers. )

Frist has basked in the attention. He appears regularly as a party spokesman on television. On one of his missionary trips to Africa-Frist is a devout Presbyterian-he toured AIDS-ravaged countries with rock star Bono. And his recent book on bioterrorism-billing him as "the Senate's only doctor"-was a bestseller.

The publisher of Frist's book confirmed yesterday that Eli Lilly and Co. helped boost the book by purchasing 5,000 copies, which the pharmaceutical giant distributed in 13 cities as part of an educational effort to help health care professionals deal with bioterrorism. Jed Lyons, president and CEO of Rowman & Littlefield, said the sales had resulted from the company's marketing to corporations, and neither Frist nor his staff had had anything to do with the sale or were aware of it. Under Frist's contract, Lyons said, all royalties go to two Tennessee charities designated by the senator. "Bill Frist is way too smart to risk his reputation by trying to make a special sales arrangement with corporations that could embarrass him," Lyons said.

Nevertheless, Frist has close ties to Lilly, which has been a major contributor to his campaign and to the NRSC when he was chairman. Frist wrote a provision, enacted into law, that restricted the ability of plaintiffs to sue the company for injuries resulting from Thimerosal, a mercury-based preservative used in vaccines against childhood diseases. The Lilly provision was quietly woven into the legislation creating the Department of Homeland Security .

Even his political opponents say Frist has been an astute and willing negotiator on health care issues-though seldom willing, in the end, to stray far from his conservative views. Rich Tarplin, assistant secretary for legislation at the Department of Health and Human Services during the Clinton administration, recalled working with Frist on a law in 1997 that vastly strengthened the Food and Drug Administration's regulation of tobacco. Tarplin said he was struck by Frist's "ability to synthesize very, very complex subject matter"-a facility Frist demonstrated two years later when they worked together on highly charged legislation to revise the nation's method of allotting human organs for transplants.

Frist has also worked to provide greater access to health care in impoverished communities-including programs to train minority doctors and nurses. A policy analyst called Frist "a Boy Scout in all the positive ways," though a political consultant added that he can come across as "sickly sweet and condescending."

Smooth demeanor, mixed with dependable conservatism, has helped to make Frist a favorite in the Bush administration. Though he volunteered in 1992 to support the first President Bush's reelection campaign, Frist caught the attention of Team Bush when he was touted by then-Sen. Paul Coverdell (R-Ga.), the Bush liaison in the Senate. Coverdell's death in 2000 left a hole in the campaign, and Frist stepped in. Soon after, he found himself co-chairing the GOP platform committee.

For a while, at least, his closeness to the White House may trouble more than help him. Senate insiders predict he will be watched closely by GOP senators who resent a president trying to tell them-directly or indirectly-what to do. Democrats likely will dare him to stand up to Bush whenever they see a chance.

In one recent example, several Democrats chastised Frist for failing to get the $500 million he said was needed to fight AIDS in Africa. After initial promises, the White House cut the funding dramatically, then restored it in phases, then killed it in a larger fight over spending. Frist has said he still hopes to get the money.

Almost since his arrival in Washington, people have wondered how high the doctor would rise. Lott told friends several years ago that Frist was a likely successor. Others believe he has his sights on the White House in 2008. By stepping up to the current crisis, Frist has turned such speculation into a stern test. It has been said that politics isn't brain surgery-but it isn't heart surgery, either.

Staff writers Amy Goldstein and Dan Morgan contributed to this report.

© 2002 The Washington Post Company

http://www.washingtonpost.com/wp-dyn/articles/A20079-2002Dec20.html

Posted by pnhp at 09:47 AM | Permalink | Comments (0)

Capitalist Taiwan (the Republic of China) has had such a single-payer scheme since 1995. Malaysia may well be inspired by that system.

Oddly enough, the Communist Peoples Republic of China on the mainland has a basically capitalist health system with millions of uninsured, among them all children. Employed persons in urban settings are covered by a form of social insurance system, but not their children. There's virtually no insurance coverage in rural areas. Finally, there's not much of a safety net. Hospitals are not set up to give charity care. There's no one to shift costs to.

Happy holidays,

Uwe Reinhardt

Posted by pnhp at 09:29 AM | Permalink | Comments (0)

Don, We have a lot to learn from Malaysian doctors. I hope this gets into a letter to the editor of The NY Times or The Post or somewhere.

Also, I might add that the discussion of health finance and the principles of distribution would be advanced if more American policy makers read through the Kirby and Romanow Reports on Canada's Medicare. Both review what Medicare is meant to do, where strain has arisen, and why neither wanted to change the fundamental structure. They were meant to disagree some, but in the end the similarities are striking. And the premises are worth bringing into the US discussion directly.

Ted Marmor

Comment: Professor Marmor is right. Start writing those letters and opinion
articles now, and contact your legislative representatives ASAP.

Romanow Report:
http://www.healthcarecommission.ca/

Kirby Report:
http://www.parl.gc.ca/37/2/parlbus/commbus/senate/com-e/soci-e/rep-e/repoct02vol6-e.htm

Malaysian Medical Association support of universal government insurance:
http://www.emedia.com.my/Current_News/NST/Monday/National/20021223073302/Article/

Posted by pnhp at 09:41 AM | Permalink | Comments (0)

New Straits Times
December 22, 2002
MMA seeks health cover for all
By Pritam Singh

Kuantan, Dec 22: The Malaysian Medical Association (MMA) has proposed to the Government the setting up of a national health financing scheme that will provide coverage for all citizens.

MMA president Datuk Dr N. Athimulam said under the proposal, already presented to Prime Minister Datuk Seri Dr Mahathir Mohamad, the young would subsidise the old, and the rich would subsidise the poor.

"The MMA feels any insurance scheme should be owned and run by the Government, and operated as a non-profit entity," said Dr Athimulam at the 20th annual installation dinner of the MMA's Pahang branch here last night.

Dr. Athimulam said insurance schemes run by private companies were profit-oriented and were only willing to insure the healthy.

"The private sector should not compete with the scheme, but complement it, and the Government should be the single payer of medical expenses."

http://www.emedia.com.my/Current_News/NST/Monday/National/20021223073302/Article/

Comment: If only the leadership in the United States would abandon their third world" approaches to health care and follow Malaysia's lead in advocating for a civilized health care system.

Posted by pnhp at 09:21 AM | Permalink | Comments (0)

The Modesto Bee
December 22, 2002
Bridging insured-uninsured gap becomes fiery health care battle
By Jim Sanders

(California State Senators Sheila Kuehl and Jackie Speier) each are preparing legislation for universal health care, but their approaches differ significantly in style, financing and scope.

Kuehl is pushing for a complete overhaul - a "single payer" system - in which the state would replace insurance companies in collecting monies, contracting for medical services, and paying doctors and hospitals for services rendered.

Kuehl contends that the program would not cost more than is now spent statewide for health care. Conceptually, the program would rely on various taxes, not insurance premiums. Expansion could be supported partly from savings in administrative costs and through bulk purchasing, she said.

Doctors would have wide latitude to determine appropriate care under Kuehl's proposal. The managed-care system would be replaced by one that relies on medical experts, under the auspices of an elected state health commissioner.

By contrast, Speier wants to build on the existing system, leaving private insurance in place but filling the gaps.

Speier proposes a "play-or-pay" system, Senate Bill 2, that would require employers to provide medical benefits or pay taxes toward creation of a publicly subsidized plan, Healthy California, to provide basic benefits to those lacking insurance.

The California Labor Federation also is developing a "play-or-pay" proposal that would reduce the ranks of the medically uninsured while retaining health care as a central element of collective bargaining.

Sen. Sheila Kuehl:

"Where we used to talk about whether we should attempt universal health care, the argument seems to have shifted to how we can accomplish it."

http://www.modbee.com/local/story/5679831p-6653530c.html

Comment: Fortunately, the California Health Care Options Project was not just one more study of reform to be filed away, having no more impact than a footnote in future treatises on failed efforts at reform. The findings of the study are now being translated into legislation that actually offers real hope of reform.

Most of the major hurdles are still ahead, but at least we've broken from the starting gate. Let's begin with the assumption that we will have universal health care, and let's direct our efforts to identifying and adopting policies that are in the best interests of patients. That way, we'll all be winners.

California Health Care Options Project:
http://www.healthcareoptions.ca.gov/

Posted by pnhp at 09:53 AM | Permalink | Comments (0)

I'm glad to see James A. Morone's proposal has put single payer back in the national debate.

As you say, a value added tax and an employer option for supplementary insurance, could be considered "details" that might divert attention of "some single payer advocates." However, I believe that every single payer advocate should find the provision of "automatic coverage for all legal residents of every age" a deal breaker.

Those of us who are single payer advocates in California will remember the very bad repercussions in 1994 (and into the following years) because Prop. 186 didn't provide coverage to the undocumented.

We know from studies that the savings single payer achieves can fund high quality health care for all. Drawing on the findings for the single payer proposals in the state's Health Care Options Project, for example, Senator Sheila Kuehl is committed to a single payer bill that will provide coverage to all California residents.

I hope in the future you can use the message of the day to raise a discussion about real universal coverage with single payer versus the kind proposed by Mornoe.

Dan Hodges

Posted by pnhp at 09:54 AM | Permalink | Comments (0)

Comment on Sen. Bill Frist and Medicare:

In the recent election, Sen. Frist counseled the Republican candidates to support prescription coverage for senior citizens but without providing any of the specifics of their proposal. The Republicans will now have to deliver on that promise even if their proposal will be inadequately funded, and will primarily benefit pharmacy benefit managers, private insurers and pharmaceutical firms, while providing little benefit for patients.

Most agree that give-back legislation will be important to prevent the exodus of providers from the Medicare program. But the Republican insistence on budget-neutral adjustments does not bode well for maintaining the fiscal integrity of the Medicare program. This is more bad news for Medicare patients.

Sen. Frist strongly supports Medicare privatization through the Breaux-Thomas-Frist premium support proposal. Regardless of their "marketplace competition" rhetoric, the real purpose of shifting from the public program to private plans is to reduce public costs by allowing "more affordable" private plans that shift more costs to patients, while simultaneously supporting the private, middleman health plan industry.

Republicans will continue to block prescription coverage through the traditional Medicare program, authorizing only a separate benefit by private insurers. By doing so, Medicare beneficiaries will be incentivized to exit the public program and enroll in private plans.

If these issues are addressed individually, the Democrats can muster enough support by exposing the nefarious policies behind each issue. It is much more likely that Sen. Frist will orchestrate a plan to present an omnibus bill that "provides prescription coverage, controls Medicare costs by modernizing the program, and assures the viability of providers by reducing some of the scheduled cuts in funding." Superficially, the package may have broad appeal and gain the support of conservative Democrats that barely survived the last election. These Senators would have little to lose and some to gain by supporting a package that may look good to voters and that really doesn't cost much at a time when more tax cuts are on the agenda.

Sen. Frist, by "saving Medicare," will further his personal ambition to assume the number two spot on the 2004 ticket as a step toward the number one spot in 2008.

Although enacting comprehensive reform will be impossible in the next two
years, it will be imperative that we make every effort to:

(1) Protect Medicare as a program of social insurance by opposing privatization efforts,
(2) Fight for a prescription benefit that is incorporated into Medicare's program of social insurance, and
(3) Assure that adequate give-back provisions are passed that do not parasitize some sectors of Medicare providers for the benefit of others.

Please accept my apologies for this blatantly partisan commentary. But only the Republicans have it in their power to save Medicare through a bipartisan effort that supports the Democratic positions on these issues.

Don McCanne

Posted by pnhp at 09:56 AM | Permalink | Comments (0)

Health Affairs
November/December 2002
How And Why The Health Insurance System Will Collapse
By Humphrey Taylor, Chairman of the Harris Poll

Abstract

The advocates of defined-contribution health plans extol the virtues of consumer-driven health care, consumer choice, and empowered consumers as solutions to the problems--particularly the rapidly growing costs--of employer-sponsored health benefits. This paper argues that the widespread use of defined contribution plans, with more consumer choice and more knowledgeable consumers, will lead to the erosion of the social contract on which health insurance must be based, with healthier employees subsidizing the care of older and sicker ones, and a death spiral of adverse selection. If unchecked by government intervention, these trends will lead to the collapse of employer-sponsored health insurance.

http://www.healthaffairs.org/1130_abstract_c.php?ID=http://www.healthaffairs.org/Library/v21n6/s28.pdf

Posted by pnhp at 09:41 AM | Permalink | Comments (0)

Economic and Social Research Institute
November 2002
Covering America: Real Remedies for the Uninsured
Volume II

Medicare for All

James A. Morone has proposed a single-payer approach to provide universal coverage with the following elements:

* The Medicare program with expanded benefits, including no cost sharing, would provide automatic coverage for all legal residents of every age.
* Funding would come solely from revenues raised by a new federal value-added tax.
* States could opt out (for residents under age 65) by proposing a program that meets federal guidelines and by paying 25 percent of the cost.
* Employers could offer coverage for additional benefits, with the employer-paid premium not subject to income tax.

http://www.esresearch.org/newsletter/booktwo/CovAm2.htm

Comment: Three new proposals for comprehensive health care reform have been added to the ten proposals presented last year by the Economic and Social Research Institute. Of great significance is the fact that this single payer, Medicare for All proposal has helped to place this concept back into the national debate over the various options for reform. This is another crucial breakthrough since the single payer option has often been explicitly excluded from the forums on reform (as it was in the ESRI report last year).

Some single payer advocates might be concerned about a few of the features of Professor Morone's proposal, such as the value added tax (VAT) and an employer option for supplementary insurance. He ameliorates, to some degree, the regressive nature of the VAT by exempting food, medicine and shelter, and by expanding the earned income credit to families with incomes up to $45,000. Also he limits the employer supplement to extra benefits such as hospital amenities.

But rather than diverting attention to various details of his proposal, we should direct our efforts to being certain that the fundamental single payer message is included in all forums, discussions and deliberations. America can only benefit by making health care reform a fully informed process.

Posted by pnhp at 02:46 PM | Permalink | Comments (0)

Partnership for Solutions
A Project of Johns Hopkins University
and The Robert Wood Johnson Foundation
"Chronic Conditions: Making the Case for Ongoing Care"
December 2002

In the coming years, our health care system will devote increasing amounts of resources-both services and dollars-to care for people with chronic conditions. As a society, we need to ensure that these resources are spent as effectively and wisely as possible to maintain the health and enhance the individual functioning of this large segment of our population.

Care provided in the current system is not cost-effective and often leads to poor outcomes for patients with chronic conditions.

Providers, patients, and the public recognize that adjustments within the health care system are needed to improve chronic care in this country. In order to make these adjustments, health policymakers will need to reexamine how our current health care financing system values and pays for care received by people with chronic conditions, how we train health care providers to treat chronic conditions, and how the needs of people with chronic conditions are met.

http://www.partnershipforsolutions.com/

Comment:

From the Introduction:

This chartbook outlines the challenges the health care system continues to face in using its resources efficiently and effectively to provide access to high-quality, coordinated care and appropriate services that maintain health and functioning for people with chronic conditions.

Posted by pnhp at 04:34 PM | Permalink | Comments (0)

By D.R. Bahlman
Berkshire Eagle Staff
Monday, December 16, 2002

PITTSFIELD -- Support for a single-payer health care insurance system appears to be gaining among health care providers in Berkshire County, according to a survey conducted by a Great Barrington physician.

Dr. David Lippman said that, of those who responded to his survey of all practicing physicians in the county, 86 percent stated that they might favor a single-payer system. The survey was sent to members of the Berkshire District Medical Society; he could not provide exact figures about the numbers of surveys sent out or returned. He noted that many of the county's health care providers were not surveyed because they are not on the rolls of the medical society, which has about 200 members. He also said that a wide range of opinions were expressed.

"Some said they wanted the government out of it entirely," he said.

Lippman and other members of MassCare, a statewide organization that advocates for a single-payer "universal" health care system, note that Massachusetts residents pay the highest health care costs in the nation -- 30 percent above the national average per person, according to a 2000 study by two Boston University researchers -- and that a single-payer system would reduce those costs substantially.

"The whole state will pay less for health care under a system that will cover every single person in the state," said Jean Dillard of Lenox, a nurse who is a member of MassCare. "If such a system had been instituted in 2000, the state would have saved approximately $1.2 billion in that year alone."

Citing the BU study, Dillard declared that "the biggest things we're paying for now are administrative costs and the million-dollar salaries of CEOs of insurance companies and pharmaceutical companies."

Under a single-payer system, said Dillard, "you could forget those costs, forget the costs of advertising that those companies and some hospitals and some doctors do, forget about costs of the bodily injury coverage in auto and homeowners' insurance policies and the bodily injury portion of Workers' Compensation."

Citing statistics indicating that between 400,000 and 600,000 Massachusetts residents are currently without health insurance coverage, Dillard acknowledged that there would be a cost associated with entitling them to such coverage, "but they all won't be sick at once."

A "two-tier" system that combines state-funded universal health care with private health care-cost indemnity coverage wouldn't work, said Dillard.

"The 'healthy-wealthy' will have the private coverage and that will leave all the expenses for the sick and poor," she said. "The state has got to be the insurer."

Lippman said that the benefits of a single-payer system also include uniformity of fees for service.

"It's embarrassing that [universal access to government-funded health care] isn't available in the world's wealthiest nation. There's something about medicine and something about money that's like oil and water: They don't mix," he said.

Posted by pnhp at 09:26 AM | Permalink | Comments (0)

By Liz Kowalczyk, Boston Globe Staff, 12/15/2002

During the past six months, Dr. Eugene Fierman and his two colleagues were showered with offers worth thousands of dollars.

At least once a week, the nation's pharmaceutical firms invited them for ''educational evenings'' at some of the city's priciest restaurants, including cocktails and dinner at Radius paid for by Pfizer, an insomnia discussion at Locke-Ober, and a depression talk at Maison Robert - both on Wyeth's tab.

Drug firms through intermediary companies paid for at least 50 hours of free continuing medical education courses, which the psychiatrists could complete by phone, mail, on the Internet, or at hotels - required courses for doctors that traditionally were the province of medical schools but now are increasingly funded by the industry.

Some pharmaceutical companies wanted to hire them as temporary advisers, including Forest Pharmaceuticals, which promised the doctors $500 each for listening to a Saturday morning talk about the firm's new antidepressant, Lexapro, at a Cambridge hotel and then providing ''advice and feedback.''

And occasionally, drug company employees dropped off at the doctors' rented office at Faulkner Hospital small gifts: a box of cookies from the Wyeth salesman, four classical CDs from the Pfizer representative.

With investigations into the industry's sales tactics growing, and a new voluntary code of conduct in place that stresses educating rather than entertaining doctors, Fierman, Dr. Ann Potter, and Dr. Gregory Harris - like many of their colleagues throughout the medical profession - said sales representatives now rarely offer the most lavish gifts that were routine in past years: theater tickets, golf trips, and resort weekends.

Instead, drug makers are paying for or offering more consulting opportunities, even for one evening, continuing medical education courses, and dinners billed as educational events with specialist speakers. At the Globe's request, the three doctors kept track of pharmaceutical-related invitations and offers they received over a five-month period. The material was enough to overflow a 1-foot-square, 2-foot-high box.

''It's hard to resist all this money and free stuff floating around,'' said Harris. ''But it's a slippery slope, and I don't want to be in the position of doing something that crosses the line.''

The shift in the tactics drug companies are using to establish close relationships with doctors was occurring even before the industry adopted the new guidelines in July. The amount of money pharmaceutical firms spent on meetings and events, including continuing medical education, teleconferences, dinners, symposia, and get-togethers with physician advisers, more than doubled over four years to $2.1 billion in 2001, according to Verispan, a company that tracks promotional spending.

Drug industry funding of continuing medical education courses alone last year totaled $540 million, and the national organization that accredits continuing medical education providers has become so concerned about potential bias that it plans to issue stricter rules as early as January.

Drug makers say these classes and gatherings provide physicians with crucial information about medicines that could help their patients - and allow doctors to speak to each other about their experiences. But Dr. Marcia Angell, former editor of the New England Journal of Medicine, said the danger is that companies simply disguise marketing as education, while slanting presentations toward their own products and helping to increase health-care costs.

''These companies are in the business of selling drugs, period,'' Angell said. ''It's ludicrous to think you'd look to a company for education about a product they're trying to sell.''

Physician leaders also are concerned about what they see as a rise in consulting and question whether doctors are providing meaningful advice to the companies - something required by the new guidelines - or are merely being paid large sums to listen to a sales pitch. And federal law prohibits companies from offering doctors cash inducements to prescribe their drugs. Dr. Sidney Wolfe, director of Public Citizen Health Research Group in Washington, D.C., said some consulting fees have gotten so high that he believes they border on illegal inducements. He has referred several cases to the US inspector general.

With the focus on drug industry marketing intensifying, doctors are increasingly concerned about their interactions with sales reps, and some are taking steps to limit their visits - or keep them out of their offices entirely. But that - Fierman, Harris, and Potter discovered - is not so easy.

The doctors decline consulting offers, and they no longer attend dinners. The cookies go to Bill Johnston, the practice's part-time receptionist, who brings them to his fellow band members. Their one concession: They accept drug samples for uninsured patients, a marketing tool on which the drug industry spent $10.5 billion last year.

In early summer, Potter felt the practice was overrun with Eli Lilly salespeople. One day, she found a 22-year-old sales representative in the waiting room talking to a patient. Potter called his manager and requested only one Eli Lilly sales visit a month. The manager said no. The reason: The doctors get too many samples, he said. They gave in to two visits a month - as long as they got to choose the sales rep - even though they know samples probably increase their prescribing of those particular drugs.

''You can't totally drop out of this crazy system,'' Fierman said.

`Dinners are exploding'

At least once a week between August and November, sales representatives invited Fierman, Harris, and Potter for cocktails and dinner. The most modest restaurants: Figs and the Newton Marriott. The most posh were Radius, the Ritz-Carlton, and the Four Seasons - all dinners they didn't attend.

Dr. Ronald Katz, an internist in a large, busy practice on Beacon Street in Brookline, said ''dinners have exploded in the past couple of months,'' which he believes are ''in lieu of trips and the most expensive things they used to do.''

The industry's new code of sales conduct requires dinners be ''modest as judged by local standards'' - a guideline some companies are complying with and others are not.

''This should not include the city's most expensive restaurants,'' said Jeff Trewitt, a spokesman for the industry trade group, the Pharmaceutical Research and Manufacturers of America. ''We want there to be no distractions. We want the focus to be on a meaningful conversation about a new medicine and its potential value and characteristics.''

Dr. Susan Black, a family practice doctor in Tewksbury, drove into the city one night this fall for a dinner and discussion at the Four Seasons on urinary incontinence in women, sponsored by Pharmacia, which makes a drug for overactive bladder called Detrol LA. She earned one hour of continuing medical education credit; Massachusetts doctors must earn 40 hours of medical education credits with an approved provider every two years to remain licensed.

''They were discussing their own research, the company's research. And they were trying to show the drug was better than their competitor's,'' Black said. ''I thought I should go because this is a big issue for my older patients. There are some really good new physical therapy approaches and surgical approaches, but they didn't discuss those.''

Executives at Pfizer, which has paid for dinners at pricey restaurants in Boston since July, said the choice of restaurant is a ''judgment call'' made by local sales reps.

''The price of the meal is so inconsequential, given what we're grappling with around the guidelines and what's educational or not,'' said Dr. Mark Horn, Pfizer director of medical alliances. ''I would focus on the speaker, the content, and the quality of the presentation. As long as it's balanced and fair, I'm less concerned with the selection of the eateries.''

Many education courses

Last Thursday at 1 p.m., Fierman called a toll-free number to earn one hour of continuing medical education credit listening to a teleconference called ''Stabilizing the Dopamine-Seratonin System: A New Era in the Treatment of Psychosis'' - one of dozens of free, pharmaceutical-company-funded continuing medical education courses offered to the practice during the past six months.

This course, which Fierman enrolled in at the Globe's request, was organized by a private California company called Continuing Medical Education Inc. and paid for with an unrestricted grant from Bristol-Myers Squibb and Otsuka America Pharmaceutical. The companies in November received approval from the Food and Drug Administration for a new antipsychotic medication called Abilify.

As Fierman listened from his small office overlooking Arnold Arboretum of Harvard University, Dr. Peter Weiden, director of the Schizophrenia Research Program at SUNY Downstate Health Science Center in Brooklyn, began with a history of antipsychotics and a description of why newer drugs like Zyprexa and Risperdal are superior to older medications like Haldol. (Fewer side effects like tremors.) But he devoted more than half the hour to the benefits of Abilify, often referring to it as ''the new kid on the block.'' Although companies are not allowed to promote unapproved drugs, Continuing Medical Education Inc. began offering the course before Abilify was approved, something allowed under continuing medical education rules.

Fierman said the science in the class was sound, and that Abilify might very well be the next blockbuster for the mentally ill. But he said advertising the course as an objective class on brain receptors was misleading. ''If this were a lecture saying we're introducing our new drug, that would be fine,'' he said.

Drug companies usually aren't accredited continuing medical education providers themselves. They pay for the classes offered by medical schools and accredited third-party companies like Continuing Medical Education Inc. In this case, Continuing Medical Education Inc. suggested the class topic to the drug firms and they had no input into the content, said Steve Mandell, the company's vice president of sales and business development.

But Dr. Murray Kopelow, chief executive of the Accreditation Council for Continuing Medical Education, which oversees the continuing medical education system for doctors, said third-party companies and medical schools may have grown so dependent on drug companies for their livelihood that they're no longer independent providers and have lost control of the agenda - and sometimes the content.

''These relationships have complicated the situation,'' said Kopelow, whose organization will consider sending physician volunteers to monitor the courses for commercial slant. ''There's probably more bias than we know.''

Consulting offers grow

Pharmaceutical companies, physicians said, also are pushing to increase their consulting relationships with them. Drug firms for years have hired respected physicians, often referred to as ''thought leaders,'' to speak about their drugs at conferences and serve on advisory boards. Some doctors earn thousands of dollars from these extracurricular activities.

But some doctors said drug firms are offering more small, one-time consulting opportunities. And Fierman, Potter, and Harris received dozens of requests from drug marketing research firms - whose clients are pharmaceutical companies - to provide their opinions for a fee on the effectiveness of proposed direct-to-consumer ads and even report on how often competitors' sales reps visited their offices.

Other physicians reported similar offers: Novartis promised Dr. Richard Parker $300 to give ''feedback about hypertension'' and Dr. Martin Solomon $500 to provide advice on hormone replacement therapy.

Eli Lilly promised Dr. Jonathan Moray $750 to attend a dinner meeting on therapy for attention deficit hyperactivity disorder and ''provide his perspective on ... potential new treatment options.''

Novartis spokeswoman Christine Landy said the company ''needs this feedback to guide future marketing and research'' and draw up written contracts - as required by the sales code - to clearly outline the doctor's role. But most of these dinners include a presentation about a drug the company makes or is developing.

''The companies used to call it coming to dinner,'' Solomon said. ''Now it's called consulting.''

Potter attended a consultants dinner meeting in the spring for which she was paid $400. The company, which she did not want to name, asked physicians how to catch their attention so they would prescribe the firm's antidepressant.

''I thought, `What am I doing here?' It was advice,'' she said, ''but it was advice on marketing.''

Alice Dembner of the Globe Staff contributed to this story.

This story ran on page A1 of the Boston Globe on 12/15/2002.
© Copyright 2002 Globe Newspaper Company.

Posted by pnhp at 02:48 PM | Permalink | Comments (0)

American Medical News
Dec. 23/30, 2002
More big firms want Web-based health plans
By Tyler Chin

Based on a survey of 25 large companies with more than 1,000 employees each, 16% of large employers will offer Web-based health plans to employees in 2003. This is up from 4% in 2002, according to estimates by the Cambridge, Mass.-based consulting firm. That number will rise to 40% in 2004, the firm said.

Large employers are interested in offering Web-based plans because they are looking for ways to lower health care costs, said Bradford J. Holmes, the firm's research director.

Web-based plans let patients contribute a certain amount toward their health care costs and control how they spend money in their personal health care spending accounts

http://www.ama-assn.org/sci-pubs/amnews/pick_02/bisb1223.htm

Comment: Consumer-driven health care is here. Are we ready to accept the consequences of shifting costs to those with the greatest health care needs?

Posted by pnhp at 01:38 PM | Permalink | Comments (0)

By Jack Markowitz
FOR THE TRIBUNE-REVIEW
Sunday, December 15, 2002

For astronomical numbers, there's no reason to look beyond earth. The head spins perfectly well contemplating health care in the United States, increasingly called a "crisis."

We are spending $1.5 trillion on it this year, 15 percent of gross domestic product. Two decades ago, it was 8 percent. We outspend every other country in the world to stay — but more often to get — well. Five percent of us, when sick, generate 60 percent of the bills.

The cost approaches $5,000 a year for every man, woman and child, even though 42 million of us go out into the risky day without a dime of medical insurance.

Meanwhile, the average new doctor graduates from medical school $125,000 in debt, and veteran docs are retiring early as never before. Malpractice premiums are killing them. On the other hand, medical errors kill an estimate 500 people a day in this country, while our lawmakers drive up insurance costs by "mandating" more coverages that their voters want. Prescription drug subsidies are just over the horizon.

There's a sense that something's got to give. What if it should prove to be freedom?

Don't think socialized medicine died in the defeat of Hillary Clinton's 1993 national health scheme. It gets stronger legs every day under a new euphemism: "single-payer insurance." The single-payer being the government. Meaning the taxpayers. All would pay for all under the illusion that insurance for everybody can somehow be "free" for the needy.

The University of Pittsburgh and Pfizer Inc. recently aired some of these paradoxes at a "mini-medical school" for members of the public.

Hospitals "make a lot of money at the end of life," Jeffrey A. Romoff bluntly pointed out. "We make no profit on prevention."

Romoff is president of UPMC Health System, Pitt's medical offshoot that's now the region's largest employer: 36,000 jobs, 20 hospitals, annual research funding of $250 million. Next step for free marketers, he suggested, ought to be to recruit manufacturers of pharmaceuticals and medical devices. But marketplace solutions will appeal less in the giving of care itself. Consolidations of hospitals will continue ("the big are eating the little") and medical insurance providers, even if private, are apt to come down to an oligopoly of "3, 4 or 5" giants.

Dr. Arthur S. Levine, dean of the Pitt medical school, said 75 percent of health care costs stem from "preventable illnesses" rooted in negative habits and life styles. If we'd all draw up "living wills" to discourage hopeless treatments for terminal illnesses, he said, the country might save enough "to insure all the uninsured." Genetic research offers the hope of getting at 5,000 to 10,000 "targets" in the human cell to fight disease. All drugs currently on the market have only 300 such targets.

Among the forces driving health costs higher, Professor Judith R. Lave cited a backlash against 1990s-style managed care. But the aging population, although often blamed, does not seem to be a major factor. Baby boomers are no slouches as medical consumers.

By 2010, health care looks to absorb 16 percent of an ever larger GDP. This may be scarier than it sounds. We are, after all, a service economy; manufactured goods take fewer of our dollars. And some health costs are under personal control, by way of personal habits.

The "crisis" may turn out to be this: Can the values of free markets and personal liberty keep that single payer out of our lives?

Posted by pnhp at 11:50 AM | Permalink | Comments (0)

By MARTIN DYCKMAN, Times Associate Editor

© St. Petersburg Times
published December 15, 2002

TALLAHASSEE -- One of the perils of being a public official is to mingle with and take favors from people he will have reason to wish he had never met. (Remember the Keating Five?). Most recently, it happened to Gov. Jeb Bush.

He took a pasting in the press over private jet trips and campaign contributions provided by a company called National Century Financial Enterprises and its founder, Lance K. Poulsen. National Century was hit last month with a $3.5-billion fraud suit, filed for bankruptcy, and involuntarily welcomed swarms of FBI agents and accountants to its Ohio headquarters.

But the real story, universally overlooked, was bigger than the efforts of yet another questionable entepreneur to ingratiate himself with one of the Bushes. It had to do with the nature of the perfectly legal business that National Century was in.

That business was to finance doctors, hospitals, nursing homes and other health care providers while they waited -- and waited, and waited -- for money owed them by health insurance companies, HMOs, and Medicare and Medicaid.

Every dollar in profits was a charge against the nation's overall health care bill. Not a penny of it made any sick person well.

There would be no place in an efficient or humanistic health care system for a practice like that.

It must be an awfully lucrative business, however, because there are other companies in the field.

They do it by buying accounts receivable at a discount and pocketing the difference when they finally collect the unpaid bills. It comes as no news that health insurance companies stall on paying out for as long as they think they can get away with it.

The business of buying accounts receivable is known as factoring. It is common in other lines of commerce.

But health care is not, or ought not to be, just another line of commerce. It's a matter of life or death for everyone. It should more resemble a religion than a business.

Instead, health care has become the biggest of businesses. Overall, America will spend an estimated $1.5-trillion on health care this year. That's more (often more than twice as much) by every measure -- total, per capita, percentage of gross domestic product -- than any other developed nation. Yet for more than 40-million Americans, those with no health insurance of any kind, the doors of this business are closed except on an emergency basis, when it is most costly and often too late.

A shocking amount of this money -- $112-billion this year, according to government data -- is written off to what it calls "government administration and net cost of private health insurance." The private sector accounts for most of that.

Another significant statistic, according to the Organization for Economic Cooperation and Development, is that 27 of 28 other countries spend proportionately more of their total health costs out of public funds than we do. (The exception is South Korea). The OECD average: 74.1 percent. The United States: 46.4.

Many of the others are healthier, though whether it's for better medical care or for eating less and walking more would be hard to say.

None squanders money the way we do in ways that make people richer but not healthier: on swollen profits for HMOs, hospital chains and the like.

Everywhere else, private health insurance is a small slice of the pie. Here, it's nearly 35 percent. France, at 12.8 percent, and Germany, at 12.5, come next.

Speaking of France, the total bill for a routine visit to the doctor is $20, and the Securite Sociale refunds the patient most of that.

The United States could afford good health care for everybody with the money we would save by getting rid of the middlemen.

Sam Gibbons, the former congressman, had the right idea: Medicare for everyone.

Medicare has its faults, chiefly in the exclusion of pharmaceuticals and preventive care. It also pays less than the doctors and hospitals say they need. But it is not as slow to pay as the private insurers are. Unlike the private insurance companies, it has no profit motive for making the doctors wait for what they have earned. Its cost of administration is the lowest of all, and it could easily be expanded into a true single-payer health insurance system covering everyone.

This issue is coming to life again despite the calamitous defeat under the Clintons. Even Al Gore, reversing himself in barely two years, has come out for single-payer ("A death-defying act," according to the Economist.)

But that single-payer has got to be the government, not the private health insurance industry. Otherwise there will always be money to be made not from making patients well, but by stiffing the people who do.

Posted by pnhp at 09:34 AM | Permalink | Comments (0)

The New York Times
December 15, 2002
When Health Coverage Is Decided by the Calendar
By Michelle Andrews

People play chicken with their health insurance all the time. They leave their jobs and their employer-sponsored health plans, gambling that they won't be in an accident or become seriously ill before they get another job that has a group plan.

A gap in coverage, even for just a few months, could leave people responsible for certain medical bills for up to a year.

Blame the Health Insurance Portability and Accountability Act of 1996, known as Hipaa, a law that was intended to protect people when they switched plans. The law safeguards coverage for pre-existing medical conditions after a worker joins an employer's group health plan - as long as there has been no significant break in coverage. (Any period of more than 62 days is considered significant under Hipaa.)

With the economy still in turmoil and jobs harder to find, more people are failing to make this seamless transition. Many cannot afford to extend health insurance under the federal law known as Cobra, which lets workers continue policies for up to 18 months if they pay the full premiums.

Once someone has a new job, Hipaa loopholes may still be a problem. If an employer bought insurance through an association - one in four employers buys health coverage this way, as do many freelancers and small-business owners - an employee may not have the same protections as under regular group coverage.

"Associations label these plans 'group coverage' to make people think they're getting the protections they would have if they got coverage through an employer group plan," said Mila Kofman, an assistant research professor at the Institute for Health Care Research and Policy at Georgetown. "Consumers need to understand that's not the case."

When Michael Opelski, 38, of Norristown, Pa., started a new job as a sales representative for a home hardware manufacturer in the summer of 2000, he took the Golden Rule group plan offered by his employer. To get Golden Rule coverage, however, he first had to become a member of an association called the Federation of American Consumers and Travelers. Mr. Opelski said he hadn't given it a thought. But when his wife, Jean, became sick with inflammatory breast cancer, he learned how restricted his coverage was. Because Mrs. Opelski had discussed finding a lump in her breast with her doctor before joining the plan, Mr. Opelski said, Golden Rule refused to pay for her breast cancer treatments. It was a pre-existing condition, he said he had been told. She died in January at the age of 34.

If the couple had been covered by a regular employer group plan, Mrs. Opelski's breast cancer would probably have been covered under Hipaa. But their plan was something that Golden Rule calls an association group policy.

Is anyone calling for any revisions to Hipaa to close these loopholes on pre-existing conditions? If anything, political momentum is moving in the opposite direction - toward less comprehensive coverage and fewer safeguards and protections.

Coverage gaps may be among the least of our worries.

http://www.nytimes.com/2002/12/15/business/yourmoney/15HEAL.html?8bhp

Comment: Association health plans (AHPs) are being promoted as an answer to the problem of obtaining access to affordable insurance for individuals and small businesses. Theoretically, AHPs would provide the advantage of lower premiums through group purchasing. In fact, AHPs often escape some of the regulatory oversight of state agencies, allowing plans that leave large voids in coverage and that are relatively free of "government mandates." These plans might offer lower premiums than the individual market, but both financial security and health security are threatened by AHP policies.

Currently, "political momentum is moving... toward less comprehensive coverage and fewer safeguards and protections." Do we really believe that the answer to our health insurance crisis is to disassemble the system and throw the infirm to the mercies of our ever-less-compassionate society? If we are truly compassionate, then why do we support policies that nurture the money managers in health care while simultaneously supporting policies that further impair affordability and access for those with the greatest health care needs?

We already have enough resources. But we need a single, publicly-administered system of funding health care to be certain that our resources our used to fulfill our mission of providing comprehensive health care coverage and access for everyone. It's our money. Shouldn't we be demanding value for our health care investment?

Posted by pnhp at 09:37 AM | Permalink | Comments (0)

By PATRICK ARMSTRONG,
Brattleboro Reformer Staff
Friday, December 13, 2002

BRATTLEBORO -- Concerns, suggestions and possible solutions to the goal of obtaining a universal health-care system in Vermont were the topic of discussion at the second annual meeting of Vermont Citizens Campaign for Health Thursday night.

Virtually everyone present agreed that the current health-care system in the United States and Vermont does not work, including the three panelist speakers.

"It's clear that the health-care system in this country is crumbling," said panelist Rep. Carolyn Partridge, D-Windham. "I passionately believe we have to do something about it, but I'm afraid the system will really have to crumble and a disaster happen before we are able to make a change."

"The disaster's already here," said VCCH board member Richard Davis later in the meeting. "It's just a matter of how it gets portrayed."

Panelist Dr. Chris Meyer, a doctor at Brattleboro Memorial Hospital and member of Physicians for National Health, told those in attendance that the United States pays far more than other industrialized countries for health care, and that Americans receive less health care for more money, primarily because of a prodigious amount of money spent on medical bureaucracy. In addition, there are substantial portions of the population that do not have insurance or are underinsured, said Meyer.

"There is an inherent conflict between what is best for business and what is best for us, the patients," he added. "What is best for business is saving money, and business saves money by not delivering health care."

"I don't think it is morally right for people to make money off the sicknesses of other people," said Rep. Michael Obuchowski, D-Rockingham.

Meyer said that he believed single-payer health care was the solution to the health-care situation, and suggested that the first step would be to draw up a budget, based on how much is currently paid per capita on health care, to let officials know how much money that budget would need. The best way to pay for health care would be to convert everything already paid -- such as premiums, co-payments and prescription prices -- and convert it to a tax, such as a payroll tax.

People would ask if this would be the government controlling health care, Meyer said. "No more, and probably much less, than the insurance companies do," he said, adding that the government would only act as the payer for a single-payer system, and the current medical system would remain in place. Competition would still exist as well, Meyer said, because people would be able to choose their health-care provider based upon the quality of care given.

Partridge said that a payroll tax, such as having an employer pay 6 percent of an employee's income and the employee paying 3 percent, would be much less than what most companies pay now. Many insurance packages cost as much as $8,000, said Partridge.

Using a 5 percent employer contribution as a model, VCCH board member Michael Daly said that an employee would have to be making $160,000 per year in order for a 5 percent contribution to equal the cost of an $8,000 insurance policy.

"We shouldn't be scared of the numbers," Daly said. "It is just amazing how they can scare us when the numbers show such great savings."

Because companies would pay less, Partridge said, this could be used as an enticement for economic development, attracting businesses to Vermont because they would be paying less for health-care costs. A lower employer contribution would also mean property tax relief, as taxpayers would not be paying for high health insurance costs for municipal, state and school employees, she added.

Shoshana Rihn, a VCCH board member, said that small business owners had voiced concerns to her that a payroll tax could penalize employers who pay their employees well. Rihn said that it was important to include businesses in the discussion about single-payer health care, which Partridge agreed to.

"If it's not a payroll tax, that's fine with me, as long as it's the most cost effective way of doing it," Partridge added.

Marty Jezer said that a single-payer system is a complex issue that, to him, is still an abstraction. Jezer emphasized the need to find out how a single-payer system would work.

"I suggest over the next two years we have time until (Obuchowski) is governor, or someone else is governor, to do our homework," said Jezer. He suggested bringing together people to write down all the options, send them out to businesses and health-care providers for their input, and in 2004 giving all the information to lawmakers.

"For God's sake, let's stop talking about single-payer as an abstraction and get it on paper," Jezer added.

However, both Obuchowski and Partridge warned against getting into too much detail in single-payer legislation, and suggested that broader legislation would work better.

Obuchowski admitted that the status quo is "politically comfortable," and that the biggest question is coming up with reasons to shake up the status quo. There is a lack of political will, Obuchowski said, but the way to get the political will to enact universal health care is for citizens to contact elected officials.

Posted by pnhp at 03:26 PM | Permalink | Comments (0)

Health Affairs
Web Exclusive
November 20, 2002
Consumer-Driven Health Plans: Are They More Than Talk Now?
Consumer-driven plans are catching on and could be in the mainstream of
health care in a few years.
by Jon R. Gabel, Anthony T. Lo Sasso, and Thomas Rice

Over the past year medical journals, business magazines, and major newspapers have boldly pronounced that the era of heavy managed care is over and that a new era of consumer-driven health care financing is beginning.

Consumer-driven and defined contribution are two terms often used interchangeably, although they have different meanings. Defined contribution refers to an employer contribution strategy whereby employers set a fixed contribution for health insurance and place the employee at risk for costs beyond that point.

The term consumer-driven or consumer-directed refers to health plan design. Such plans generally involve a greater role for employees in choosing providers and health plans and in designing their own benefit package while assuming greater financial risk.

At its heart, the consumer-driven health care movement seeks to combine incentives with information to enable consumers to make informed choices about non-life-threatening health care. ...consumer-driven health care is an effort to put patients in a position to say no to themselves. This can happen only if consumers are aware of the true cost and have a personal stake in it, and if they have enough information and confidence to make treatment decisions.

For purposes of clarity, we classify consumer-driven plans into three loosely defined groups. The first group we term "health reimbursement arrangement" (HRA) plans because they establish an account from which consumers draw to make health care purchases. When the account is exhausted, enrollees must typically pay out of pocket until the annual deductible is met, after which the plan becomes a traditional major medical plan. A second class of consumer-driven plans allows employees to design their own networks and benefit packages. Employees' network and benefit selections determine the premium for their individual plan, and employees bear the financial risk for these choices above some fixed contribution from the employer. A third class of consumer-driven plans, termed "customized package" plans, allows employees, using Web-based tools, to choose from a predetermined selection of network offerings and benefit packages, such as a narrow, medium, or broad network and a rich, medium, or thin benefit package.

From the Discussion:

The major limitation of this study is that our information is largely from persons with a clear self-interest to report favorable developments about consumer-driven plans. Since there is limited experience and no independent evaluations of these plans to date, we depend heavily upon start-up and health plan executives, employee benefit managers, and benefit consultants for information and insights.

At their best, consumer-driven plans will provide a mechanism to inject incentive-based reasoning on the part of consumers into non-life-threatening medical care decisions. Employees do not bear most of the costs associated with higher use of care or use of more costly delivery systems. Consumer-driven products thus would reestablish the link between service use and an employee financial liability. If, as a result, employees respond to these incentives and use the Web tools not just to make decisions regarding their plan but to select providers based on quality, make informed treatment decisions, and manage chronic conditions, quality of care should improve. Customized package plans can expand the number of plan choices available to workers at small firms.

At its worst, however, consumer-driven health care can destabilize risk pools and lead to a redistribution of health care services and income from the sick to the healthy. A system that controls costs through price rather than nonprice rationing will almost certainly be to the advantage of higher-income groups and to the disadvantage of low-income groups, who are more likely to delay care if they lack the resources to pay for it.

People may be capable of behaving like rational consumers when they are purchasing prescription drugs or selecting health plans, but such rationality may elude them when they are informed that they have cancer.

If there is one message that resonates loudly from our interviews, it is this: "Political partisans, hold your fire! More research and experience are needed!" Independent research is desperately required to address the many issues we have identified. Researchers need to measure the extent of risk selection through studies that examine employees' health status before they enroll in consumer-driven plans and their competitors. Researchers should analyze the redistribution of out-of-pocket costs and services in HRA plans among the sick and healthy. We need to learn the extent to which employees are using Web tools and determine whether they are becoming better consumers and whether physicians are more or less likely to deliver care according to clinical guidelines. After controlling for risk selection, researchers need to analyze both the consumer-driven plans' ability to control claims expenses and plans' impact on health status and employee satisfaction. This is an ambitious research agenda, but surely one with a high rate of return, if the consultants and health plans are right about the future of the health benefits marketplace.

http://www.healthaffairs.org/WebExclusives/Gabel_Web_Excl_112002.htm

Comment: The very design of consumer-driven products has two precise goals: shift the costs of health care from the purchasers of the plans to the patients, and shift the risk of coverage from the insurers to the patients. This increase in cost and risk is disproportionately shifted to precisely those individuals that have the greatest health care needs. If there has ever been a non-starter in health care reform, this is it!

And we are being called on to "hold our fire," and watch another decade of economic experimentation on the American patient? Can we stand a decade of observing and measuring the grief and suffering of those that not only are faced with major medical problems, but also must submit to the experimentation that will determine the effect of adding the burden of financial hardship? Are we so lame that we can't anticipate the results?

There are winners. The healthy and wealthy will benefit. But do we want to establish policies that sacrifice those with greater health and financial needs for the benefit of the rest of us? Are we really that cruel?

No more experimentation! Health policy science has already established the fact that we can provide comprehensive services for everyone, while containing costs, simply by establishing a single, publicly-administered national health program. Let's do it now!

Posted by pnhp at 01:31 PM | Permalink | Comments (0)

By Julie Appleby, USA TODAY
December 13, 2002

Jack Perry was stunned when he started getting medical bills for a surgery he'd had weeks earlier. He had called his insurer to make sure everything was covered and pre-approved.

"I was inundated with bills from doctors," says Perry, 54, who had surgery in September 2000 to open clogged arteries in his legs.

With the tab climbing toward $20,000, the Merced, Calif., salesman repeatedly called insurer Blue Cross until he got an answer: His employer had stopped paying premiums without telling workers.

After three months, Blue Cross canceled the contract, leaving employees responsible, retroactively, for medical care provided in that period.

More than two dozen cases such as Perry's involving various employers during the past year prompted the California governor to order that something be done. Regulators there are considering requiring insurers to notify patients when employers fall behind on paying for health insurance.

"The employers are prioritizing, and sometimes health insurance premiums slip to the bottom of the list," says Daniel Zingale, director of the California Department of Managed Health Care.

Regulators expect to see more such cases as a combination of rapidly rising health insurance premiums and a stagnant economy hit small and midsize businesses. Some employers struggle to pay premiums, but fall behind. If insurance is canceled, workers might not find out until claims bounce.

It's hard to say how common the problem is nationally because few other states have a computer database that can keep track of such complaints as well as California. But regulators in other states say the problem does occur.

"We've seen it in Delaware" says Gregory Sacco, a director in the state's insurance department.

Typically, it's a smaller employer that falls behind, Sacco says. "There are usually warning signs before it happens, such as paychecks being late or bouncing."

Insurers say the problem is serious, but not widespread. Requiring insurers to tell patients could cause problems, they say.

"It's not right to have an employee get a bill from an insurer, saying your employer didn't pay the bill," says Walter Zelman, president of the California Association of Health Plans. "But we need to tread delicately and be wary that the effort to address it may create a bigger problem."

For example, Zelman says employers might be pushed to drop health insurance if the new rule doesn't give them enough time to make payments before notices go to workers.

Perry's bills were ultimately paid by Blue Cross. His company, Pacesetter Industries of Atwater, Calif., has since filed for Chapter 11 bankruptcy protection and could not be reached for comment. Perry has found another job, with health insurance. He's glad the state is considering new notification rules.

"When I spoke with Blue Cross, they said, 'It's not up to us to notify you, because you're not paying the premiums,' " Perry says. "They should have notified me so I could go to my employer."

http://www.usatoday.com/money/jobcenter/workplace/2002-12-12-unpaid-insurance_x.htm

Posted by pnhp at 09:43 AM | Permalink | Comments (0)

The New England Journal of Medicine
December 12, 2002
Homeostasis without Reserve - The Risk of Health System Collapse
By Lewis G. Sandy, M.D.

Although most observers of the health care system view the 1990s as a period of extensive instability and change, in reality the health care system, taken as a whole, exhibited remarkable homeostasis.

Now, in 2002, after a tumultuous decade in health care and in health policy, today's health care system looks remarkably similar.

Yet the turbulence of the 1990s did profoundly affect our health care system. Maintenance of homeostasis requires effort and consumes energy. The cumulative effect of the public-policy and marketplace changes of the 1990s has been the near-elimination of the system's reserve capacity and the exhaustion of available compensatory mechanisms.

A high-quality, cost-effective, and just health care system can be developed in the United States. It would require the public will to spend substantial resources on expanding coverage, willingness on the part of providers to restructure the delivery of care so as to improve quality and access, a general recognition of the limits to medicine and to spending on health services, and a social consensus on the nature and degree of inequality in our health care system. We will need to do these things sooner or later. As in the case of a patient facing a physiological assault with diminished homeostatic reserve, it would be far preferable to treat the U.S. health system as an outpatient than to wait until it is in the intensive care unit, dependent on a ventilator and on pressor therapy.

http://content.nejm.org/cgi/content/full/347/24/1971
(Available to NEJM subscribers only)

Posted by pnhp at 12:11 PM | Permalink | Comments (0)

Forbes.com
11/21/02
"Click Here for Coverage"
By Ratha Tep

Sunnyvale, Calif- based EHealthInsurance is the brainchild of an engineer named Vip Patel, 39, who started the company in 1997 after defecting from another Web healthcare start up, WebMd.

EHealthInsurance had a convincing business model. The company has formed partnerships with 135 insurance carriers, including Aetna, Cigna, Empire and HIP. It makes money as a broker, by taking an average 20% cut of the annual premium an insurer charges for those people that applied through its site and were approved for coverage. EHealthInsurance also gets 10% or so when policyholders renew their coverage, even if they don't renew through EHealthInsurance's Web site.

Vip Patel:

"I saw that the system that was in place for individuals seeking health insurance was broken and inefficient."

http://www.forbes.com/best/2002/1202/005.html

Comment: Since EHealthInsurance sells health insurance in the individual market, which is subject to underwriting, individuals with significant chronic disorders are rejected by the insurers. Coverage is limited to only a healthy subset of applicants. And paying a 20% broker's fee significantly increases the administrative waste that characterizes our system since this fee is in addition to the high administrative costs of the insurers and the administrative burden that they place on the providers.

Vip Patel recognized that the individual health insurance market was "broken and inefficient." But instead of offering measures to fix the system, he has maneuvered himself into a position to take a major cut of the action, only compounding the defects of our current system. Adding to insurance costs for the healthy and denying the sick any coverage at all is not the type of innovative reform that we need.

The administrative cost of enrolling an individual in a single, universal public insurance program for life is less than negligible. Let's eliminate the brokers along with the rest of the superfluous administrative waste in our system.

Posted by pnhp at 10:55 AM | Permalink | Comments (0)

Maine Med 'parent' offers proposal

By JOSHUA L. WEINSTEIN, Blethen Maine Newspapers
Copyright © 2002 Blethen Maine Newspapers Inc.
December 11, 2002

PORTLAND — The state's largest health-care provider offered a plan Tuesday to solve Maine's health-care crisis. The proposal requires the cooperation of health-care organizations and professionals, the federal government, state government, insurance companies, employers and individuals.

MaineHealth — the parent company of Maine Medical Center, Spring Harbor Hospital, Community Health Services and other heath providers — says a coalition that includes unions, businesses and other organizations has already pledged to cooperate.

The "Health Care Challenge" is the latest health-care reform plan released recently. Anthem, the state's largest private health insurer, offered a study in November, Gov.-elect John Baldacci has a plan and the Legislature is studying a single-payer, or universal, health-care proposal. Just last year, voters in Portland supported the concept of a single-payer system.

"There have been other plans to solve the health-care cost crisis, some more inclusive and comprehensive than others," said Bill Caron, president of MaineHealth, during a press conference at DoubleTree Hotel in Portland.

"The Health Care Challenge is different because it lays out what each interested party can and must do to achieve the goal of quality, affordable health care for everyone. It recognizes that everyone must bear some of the 'pain' of reform, and that everyone must step up to the plate."

The proposal recommends that:

l Health-care organizations and professionals — including MaineHealth affiliates — increase prices by no more than 6 percent in 2003 and limit profits to 3 percent.

l The federal government increase Medicare payments.

l The state increase Medicaid payments for physicians' services by 10 percent during 2004 and every year thereafter until they are commensurate with Medicare payments.

l Insurance companies hold profits to 3 percent or less.

l Employers continue sponsoring health-insurance coverage and individuals adopt healthy lifestyles.

Bill Cohen, a spokesman for Anthem, complimented MaineHealth for entering the debate, and said, "we agree with a great deal of the plan."

However, he wondered about the plan's call for limiting profits to 3 percent.

"We want to ... understand why they are suggesting that number, and do they totally understand the impact of that suggestion?" he said. "We can't just, in a sense, endorse it, because you've got to understand how do you work through those conflicts, but, to their credit, they've put it on paper, they've put it out there. Now all of us need to come to the table and talk about it."

Joe Ditre, the executive director of Consumers for Affordable Health Care, called the proposal "retro."

He said that "it's good that they are at least coming to the table, and saying it's a problem," but that "they still are talking about an employer-based system, they're still talking about increasing their rate, basically giving them more money and the federal government and state government giving them more money."

"Why perpetuate a very failed system?" he asked.

Ditre said it is significant, though, that MaineHealth and Anthem are getting involved in a public policy discussion.

"It says to me that both providers and insurers ... are very nervous about what's going on in our health-care system, and see the writing on the wall. I take this as a pre-emptive strike. MaineHealth wants to be involved and basically is staking its claim."

Carl Leinonen, executive director of the Maine State Employees Association, one of the organizations that endorsed the Maine Health Care Challenge, called it "just one piece of the whole puzzle," and said his organization "sees this as complementing and adding to other initiatives. Our efforts can provide positive support for the incoming Baldacci administration as it develops its specific health care proposals."

Kevin Gildart, the vice president for human resources at Bath Iron Works, who also spoke at the press conference, said "the new millennium has begun with clear indications that managed care is in transition and that new answers and innovations are needed in health care."

He said the challenge "is a significant first step" to fixing the problem.

Posted by pnhp at 09:17 AM | Permalink | Comments (0)

ajc.com
December 9, 2002
FROM NEWS SERVICES

New York -- The average health coverage premium for U.S. employees rose 14.7 percent in 2002, the largest one-year increase since 1990, according to a national study.

Health insurance costs were $5,646 per employee, compared with $4,924 in 2001, according to the survey by Mercer Human Resource Consulting, based in New York. Annual insurance premiums have risen an average 7.5 percent per employee since 1990, when they rose 17.1 percent.

To limit costs, companies have been cutting back on the plans they offer and how many employees they cover, the study said. Companies with at least 500 employees were more likely than smaller businesses to trim expensive health-management organization offerings, said study author Blaine Bos.

"Everything larger companies did created disruptions for their employees," Bos said. "[Employees] had to pay more out of pocket, and many were faced with losing the options they had elected."

About one-quarter of 2,900 employers surveyed said workers will pay a larger share of health plan costs in 2003.

"The costs are going up, and employers can't afford it," said Stephen Harri, managing director of Aon Healthcare.

Health care costs have been on the rise for the past several years due to a combination of events. The public's dislike of restrictive managed-care plans has forced health insurers to widen access to doctors and hospitals, which are charging higher fees.

Drug prices continue to surge, and new medical technologies are available for conditions once considered untreatable.

Posted by pnhp at 09:58 AM | Permalink | Comments (0)

Witchita Business Journal
December 9, 2002

Large companies in a four-state region that includes Kansas expect their health insurance costs to increase 13 percent next year.

Mercer Human Resource Consulting surveyed 119 companies with 500 or more employees in Kansas, Iowa, Nebraska and Missouri as part of a national health benefits survey of nearly 2,900 employers.

Nationwide, the Mercer survey says, employers paid 14.7 percent more to insure their employees in 2002: from an average of $4,924 per employee to $5,646. In 2003, they expect their costs to increase another 14 percent.

In the four-state Great Plains Region that includes Kansas, employers said their per-employee health benefit increases in 2002 rose 8.5 percent: from an average of $5,053 to $5,484.

Posted by pnhp at 09:54 AM | Permalink | Comments (0)

December 7, 2002
New York Times
By MILT FREUDENHEIM

orried that the growing number of uninsured patients will undermine the nation's health care system, insurance executives across the country are pressing for new steps toward universal health care.

Many health plans are developing or offering insurance with lower premiums and slimmer coverage to attract customers who cannot afford more comprehensive policies. Executives at Blue Cross Blue Shield of Montana are pressing state legislators to raise the cigarette tax to subsidize basic coverage. Another insurer, Blue Shield of California, proposed a plan this week for health insurance for all state residents. And Dr. William W. McGuire, chief executive of the UnitedHealth Group, the largest private insurer, has written to every member of Congress calling for "essential health care for all Americans."

Health insurers, which have long ranked high among the country's most disliked businesses, frame many of their proposals in public policy terms. But they also have strong business reasons to become involved in the debate over helping the uninsured. They want to add young, healthy members to their insurance pools to spread the cost of caring for the sick. They are also eager to add members whose premiums would be paid with tax money or government subsidies.

Several insurance executives also said pressures generated by the uninsured were raising a threat to the system that could lead to government intervention if insurers did not develop a plan first.

"If we don't do something in a darn hurry about the uninsured, the whole health care system in this country is going to collapse and the government will step in," said Chuck Butler, a vice president of Blue Cross Blue Shield of Montana. "People will say, enough is enough."

Dr. Jay Crosson, executive director of physician groups at Kaiser Permanente, the largest nonprofit insurer, said, "As insurance becomes less affordable, more and more people will be upset and frightened, and the industry will find itself drawn into the political process."

Most health insurers are thriving, keeping ahead of rising hospital charges and doctor fees by raising premiums as much as 30 to 40 percent a year for small companies and 17 percent and higher even for large employers. But the increases, combined with disappearing jobs, are leading many people to drop health insurance and, not incidentally, adding to the unpopularity of insurance and managed care companies.

Each 1 percent increase in costs adds 300,000 to the 41 million uninsured, according to the Lewin Group, a health care research organization. Many of the uninsured are young and healthy workers in small companies. When they go without health insurance, costs per person soar for the sicker people who remain.

People who need care keep the coverage like "people buying fire insurance when the house is on fire," said Randy Kammer, a vice president of Blue Cross and Blue Shield of Florida.

Some health insurers in the Southeast are finding that as many as one in 10 small-business customers are not renewing their coverage, according to Brian Klepper, executive director of the Florida-based Center for Practical Health Reform, a group of insurers, hospitals and employers.

But uninsured patients still go to hospitals, which then pass along the cost of unpaid bills in higher charges to health plans.

"The tragedy of our nation's health care system," said Dr. McGuire of UnitedHealth, "is that in spite of its many impressive features, it has ultimately failed to make even basic care consistently available to all of our citizens."

Dr. McGuire is calling for building universal coverage around an agreed national definition of what constitutes basic acceptable coverage, "based on firm evidence" of the effectiveness and cost efficiency of the care. He has written to every member of Congress and dispatched UnitedHealth officials to promote his plan in Washington, D.C., and in Minnesota and other states.

On Tuesday, Bruce G. Bodaken, the chief executive of Blue Shield of California, one of the largest health plans in the state, called for a statewide universal health care system, to be financed by employers, individuals and a new tax, which he said could be a model for the nation. More than six million California residents have no health insurance.

Mr. Bodaken said in an interview and a speech at the Commonwealth Club in San Francisco that under his plan, all except the smallest employers would be required to offer basic coverage. Individuals who could afford it would have to buy their own policies, and a new tax would subsidize those unable to get coverage.

Blue Shield has commissioned an independent study of taxing alternatives, including raising the state income tax, sales tax, a tax on health insurance premiums or hospital and doctors' fees and the tobacco tax.

"We absolutely have to solve this problem," said Helen Darling, president of the Washington Business Group on Health, a group of large self-insured companies. "The number of uninsured will inevitably grow because of the rapid rise in health care costs. We know it's going to get much worse."

In Florida, 30 insurers, working with Tom Gallagher, the state insurance commissioner, plan to introduce several lower-cost standard and basic policies in the spring to attract small groups that have been dropping coverage. Some policies will include high deductibles and fewer state-mandated provisions like numerous visits to occupational and physical therapists, said Ms. Kammer of Blue Cross and Blue Shield of Florida.

In Montana, insurers have lined up bipartisan support in the legislature to raise cigarette taxes at next month's session to subsidize health care for the uninsured. The package includes tax credits for employers with two to four workers, coverage for schoolteachers and for more children in low-income families, as well as prescription drugs for low-income elderly people, Mr. Butler said.

Only 2.9 million New Yorkers are uninsured, reflecting the state's extensive public assistance programs. But Howard Berman, chief executive of Excellus, a Blue Cross holding company in Rochester, said that with a projected budget shortfall exceeding $6 billion, the state will be hard put to help if more residents lose their coverage.

"We need new products for middle-class people who have been priced out," he said. "And we need more efficiency in the system to reduce costs."

http://www.nytimes.com/2002/12/07/business/07CARE.html

Posted by pnhp at 11:19 AM | Permalink | Comments (0)

Visalia Times-Delta
December 5, 2002
Editorial

Frustration reigned Tuesday among several Tulare County offices.

It was illustrated by the sight of Sheriff Bill Wittman explaining the absence of 37 percent of his line staff who had called in sick to protest their stalled contract negotiations.

It was evident in the picketing by county employees who fear rising health-insurance costs will eat most of their paychecks next year.

And the frustration was reiterated again by Wittman, who noted that his deputies are the lowest-paid in the area and pay the highest percentage of their paychecks for health insurance.

But the issue that links them all and overrides the others is health care. It is ironic the deputies used a sickout to convey their frustration, because health care is at the heart of the matter.

When will we as a state and community realize that the lack of affordable health-care insurance and care options is building to a catastrophe that crosses all interests? This week's events should tell us that, if nothing else.

We've seen the signs in the past couple of years as fewer health-insurance companies are willing to write insurance here. Doctors can't afford to practice here because the reimbursement rate for public insurance is so low. Hospitals are forced to close. Clinics and emergency rooms are overflowing. Specialists can't be lured to practice here. There is a shortage of nurses ....

And now it is evident from the crisis among public employees that even professional and middle-management workers can't afford health-care coverage.

Also Tuesday night, a small group of people conducted its monthly meeting: "Health Care for All" promotes the adoption of a universal access, single-payer health-care insurance plan. It's a radical concept that would eliminate private insurance plans in favor of one system that covers everybody and would be paid for partially with taxes now devoted to health care and partially through the premiums paid through existing plans.

That, too, is complicated. It will take a massive education effort to convince most people that it would be to their benefit.

But look what is happening with the alternative.

The deputy sheriffs are sending a message to our community: Unless we fix the health-care system, we as community will not be able to afford to protect ourselves. We will not be able to afford the public services we take for granted. We can't continue to see expenses for health care rise without the dam bursting. Tuesday we saw the cracks appearing in that dam in the form of massive employee discontent.

http://www.visaliatimesdelta.com/news/stories/20021205/opinion/512457.html

Posted by pnhp at 09:33 AM | Permalink | Comments (0)

The Center for the Health Professions
University of California, San Francisco
California Physicians 2002: Practice and Perceptions
December 2002
By Kevin Grumbach, MD, et al

Only 58% of patient care physicians in the state are accepting new patients if the patient has HMO insurance coverage. The percentage of specialists with HMO patients fell from 77% to 62% between 1998 and 2001. The rate of physician participation in private HMO plans is approaching the historically low rate of physician participation in Medi-Cal, the state's insurance plan for low income Californians. A privately insured HMO patient in California now faces almost as much difficulty as a Medi-Cal patient in obtaining a new patient appointment with a new doctor. The problem of lack of availability of physicians in many regions of the state is largely due to physicians not accepting patients with certain types of health insurance (or without health insurance altogether) rather than due to an absolute shortage of physicians practicing in California.

http://futurehealth.ucsf.edu/pdf_files/Phass2.pdf

Comment: In a personal communication, Dr. Grumbach comments:

"Definitely looks like managed care is in the retreat in CA. Only problem is that I think a lot of docs are hoping to return to the mythical 'good old days', basically charging patients directly, rather than are looking forward to a universal system under public administration. And the results from the Kaiser docs are interesting, suggesting to me that Kaiser Permanente has actually won over its physician staff with a model of managed care that seems to be more genuinely committed to quality of care and a strong culture of physician led group practice."

Posted by pnhp at 09:43 AM | Permalink | Comments (0)

By: Stephen Betts
December 06, 2002

The chairman of a state panel looking at designing a state-run, single-payer health care system said a consultant's report leaves him convinced such a system is doable.
      Paul Volenik, who represented Vinalhaven and North Haven in House District 129 for eight years until Wednesday, said the committee will make a formal presentation to the state Legislature next month.

      He said Thursday he is hopeful a single-payer system can be approved, whether it is this year or another year.

      The report by Mathematica Policy Research of Washi-ngton, D.C., finds that a single-payer system compared to the current system would either cost the same or cost 5 percent more, depending on the benefits provided under a single-payer system.

      Mathematica is projecting $8.3 billion will be spent on health care in Maine in 2004 and that will jump to $10.6 billion by 2008 under the current system.

      But Volenik noted that with the current system, 150,000 Mainers have no health insurance. He said even if a single-payer system costs 5 percent more than the current one, it would be worth it insure everybody.

      The consultants were conservative when calculating the administrative savings a single-payer system would reap, he noted. Eventually, there will be more savings as people with insurance become healthier and costs are lessened.

      The current way of financing health care, through taxes for Medicaid and privately financed insurance through businesses and individuals, would be replaced with a payroll tax, Volenik said.

      The tax could be 12 to 16 percent, he said, with one model calling for the employer to pay 8 percent and the worker 4 percent. This system would ensure that the people most able to pay would pay the most.

      He said businesses that do not contribute anything for their employees' health insurance would incur greater costs. However, some businesses would pay less, as would employees, many of whom already pay a high price for coverage.

      For instance, a person earning $20,000 annually would have to pay $800 if the employee portion of the payroll tax was 4 percent. That $800 is less than what most people pay for their share of insurance premiums, he noted.

      Volenik was a major proponent of a single-payer system during his years in the Legislature. He convinced the state to form the 19-member Health Security Board, which has been meeting frequently and hired the consultant to work on a model for a single-payer system.

©Courier Gazette 2002

Posted by pnhp at 09:27 AM | Permalink | Comments (0)

Center for Studying Health System
Change Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997-2001
Tracking Report No. 6
December 2002
By Peter J. Cunningham

Clouds on the Horizon

Continued financial pressures on physicians may decrease their willingness to serve Medicaid patients even further, potentially endangering access to care. States are experiencing serious budget pressures, and most are considering reducing or freezing Medicaid physician reimbursement to cut program costs. Rising health care costs as well as reductions in other provider payments may constrain physicians' ability further to cross-subsidize free care to uninsured patients. And access to physicians is just one concern, as more general cost-containment measures being considered or implemented by states also could affect access to hospitals and prescription drugs among both Medicaid and uninsured patients.

http://www.hschange.com/CONTENT/505/

Comment: Our current system of funding health care is not capable of assuring access to health care for low-income and uninsured individuals. This problem would be eliminated by improving the allocation of the $1.55 trillion that we are already spending on health care. The administrative efficiencies of a single, universal, publicly-administered insurance program would provide enough recovery of wasted resources to fund comprehensive services for everyone.

Posted by pnhp at 04:17 PM | Permalink | Comments (0)

Testimony of the New York Chapter of Physicians for a National Health Program
Hearing of the New York State Assembly Committee on Health
Prescription Drug Prices in New York State, December 5, 2002

        My name is Richard J. Brown. I am a psychiatrist, recently retired, who has been in practice, both institutionally and independently, for over 35 years. I additionally received an M.S. in administrative medicine from a school of public health. My educational and working experiences have led me to look beyond my immediate clinical and administrative activities into the functioning of the health care system.
        I am on the Board of Directors of the New York Chapter of Physicians for a National Health Program, an organization advocating a publicly funded, publicly administered health care system that provides equal access for all residents to quality, affordable care. Our nation is the only industrialized country that does not provide this for all our residents; more than 40 million people in the United States are medically uninsured, and a similar number are underinsured.
        It is not that there isn’t enough money to provide health care for everyone. Our country spends more on health care (more than 14% of GDP) than any other country (10.5% of GDP is the most that any other country spends.) Yet we are way down on the World Health Organization’s performance list - only 37th -- lower than Canada, Japan, and all of Europe. Ours it the only industrialized country without a national health program.
I am here to speak about the pharmaceutical industry and the cost of prescription drugs in this country and in this state. The prescription drug industry is costwise the fastest growing sector within the 14% of GDP utilized for health care. Drug spending is rising 15-20% a year - doubling every five years.
        Part of this increase is demographically driven. We are living longer, growing more numerous, and many of us require medicines for chronic conditions. The increase is also due to advances in the science and practice of medicine, including the development of newer drugs that help to manage high blood pressure, diabetes, elevated cholesterol, infectious diseases including HIV/AIDS, gout, depression and psychoses, among other diseases.
        But another part of this rising cost is attributable to unconscionable profit-taking and profligate promotional practices. The pharmaceutical industry’s average profit after all expenses including research and development, advertising, promotions, lobbying, political campaign funding, contributions to law makers, and anti-consumer lawsuits to maintain uncontrolled prices is 18-19% - that’s over three times the profit margins of the other industrial sectors.
        Looking more closely, we find that drug prices in this country average over twice those of the very same drugs in other countries. How does this happen? In every single country throughout the industrialized world except for the United States, drug prices are government controlled. Let me say that again: In Australia, in Canada, in France, in Germany, in Italy, in Japan the governments control drug prices. Also to be noted is the fact that direct-to-consumer advertising (DTCA) is banned in the European Union and Canada. Europeans visiting the U.S. are startled to see those ubiquitous “Ask Your Doctor” ads we find on TV and radio, in newspapers and magazines, and on billboards. While the industry claims that this advertising is “educational,” in yesterday’s New York Times it was reported that the General Accounting Office  Congress’s investigative arm - has found that “drug companies have repeatedly disseminated misleading advertising, even after being cited for violations, and millions of people see the deceptive ads before the government tries to halt them.” These ads are hard to escape in the United States, and as I have indicated, are not to be found in Europe or Canada.
        Promotions include lectures to physicians in expensive restaurants and often include paying the doctors up to $500 to help drive the point home that the drug being promoted is the Rolex of them all.
        The pharmaceutical industry has thus far been successful in blocking even weak federal legislation that would lower drug prices. These costs are borne by Medicaid, state programs, and private insurers, as well as by individual patients without drug coverage who sometimes have to compromise expenditures on food, clothing, fuel and other necessities of life.
        So far even modest attempts at reining in drug prices have failed at the national level. We in New York cannot afford to wait until this much-needed national reform is adopted. Other states either singly, or in partnership with other states, are beginning to take measures to control spiraling drug prices. It is high time for our great state of New York to take a leadership role in this endeavor; such a step would offer a decided benefit to our own people and to people around the country.
        As you review your legislative alternatives, I ask that you consider very seriously the necessity of controlling pharmaceutical prices in order to defend the public coffers and to make affordable drugs available to all New Yorkers.
        I thank you for this opportunity to testify before this Committee.

Posted by pnhp at 11:35 AM | Permalink | Comments (0)

Posted on Mon, Dec. 02, 2002

MORE SPACE NEEDED IN MTN. VIEW TO SERVE UNINSURED
By Truong Phuoc Khánh
Mercury News

Every layoff in Silicon Valley leaves not only one more unemployed worker but also one more unemployed worker without medical insurance. As the jobless ranks grow, one free health care clinic in Mountain View -- traditionally the medical refuge for the working poor -- is seeing white-collar workers filing into its waiting room.

They come in for flu shots, cold medicine or a prescription for high-blood pressure. As is true at all nine RotaCare clinics in the Bay Area, the visits are free. The Mountain View clinic, which operates on a shoestring budget of $250,000 aided by a cadre of volunteer doctors, nurses and translators, is looking for another, larger facility to serve the growing uninsured population.

``There's always been an uninsured immigrant population,'' said Dr. Erica Weirich, a family practitioner who donates her time to treat RotaCare patients once or twice a month. ``But recently, things have changed. We're definitely seeing much more of a mix -- individuals who have lost their medical coverage because they've been laid off.''

The first RotaCare clinic was formed by a local Rotary Club in Santa Clara in 1989 to provide free medical care to those without access to medical services.

The bulk of those who visit the clinic in Mountain View are immigrants and the working poor who labor in service-industry jobs without health benefits.

While Spanish is still dominant, a more diverse mix of languages can be heard at the clinic recently, from Farsi to Chinese to Russian.

``It's like the U.N. in our waiting room,'' said Barbara Avery, manager of outreach medical services for El Camino Hospital, a collaborator and sponsor of RotaCare. ``You're out of work for a year, things get very, very tight, and you're sick. To go to a doctor for a medical visit may be more than they can afford.''

Nicole Patakova, 39, worked as a quality controller for a technology company until six months ago.

``Good job, good pay,'' she said.

Her husband, also laid off from an electronics company this year, was recently diagnosed with high blood pressure. The couple came in the night before Thanksgiving.

Patakova said she felt uncomfortable being there.

``I've never used something like this,'' Patakova said. ``I've always worked in my life, and I've never needed help like this.''

Weirich recalled two nights earlier when a young man came to the clinic with a similar story.

``He'd been laid off, and he was actually there with a common problem, an infected ingrown toenail,'' Weirich said. ``And he was really embarrassed to be there. He said he used to have a personal doctor.''

Before 5 p.m. Wednesday, the waiting room was full. Mothers with young children. Senior citizens. Young couples who are pregnant.

Alongside first-timers such as Patakova were regulars who struggle with chronic ailments like diabetes and heart disease. Isabel Torres, 30, has been coming for six years to keep her diabetes manageable. Giovanni Arriola, 23, arrived in the Bay Area two months ago from El Salvador and had an earache.

The all-volunteer staff for the evening: two doctors, two nurses, one nurse practitioner, one nursing student, one medical assistant, one pharmacist and three Spanish translators.

Some services provided at the clinic are immunizations, tuberculosis testing, pregnancy testing, treatment for high blood pressure, diabetes, asthma, free medications and children's physicals.

A major sponsor for the clinic is the Peninsula Community Foundation, but a one-year grant is running out and the clinic is seeking additional support to help it secure a long-term lease elsewhere.

RotaCare benefits not just those who walk through its doors, Avery said, but also the community at large.

``We don't want emergency rooms flooded with patients coming in with an earache,'' Avery said. ``You don't want to eat a salad prepared by a worker who has TB.''

Posted by pnhp at 10:25 AM | Permalink | Comments (0)

Market Share vs. Health Care

by Don Bechler

Blue Shield CEO Bruce G. Bodaken's solution for achieving universal health care would have Californians paying more money while expanding Blue Shield's market share. His employer mandate/public insurance model perpetuates administrative waste and a system in which multiple health plans try to insure the healthy and avoid the sick.

Let's rid ourselves of the 300 insurance company and 69 government bureaucracies in California. Creating one publicly funded and PUBLICLY ACCOUNTABLE agency to finance all healthcare would rid us of the existing maze of bureaucracies. We would pay taxes in lieu of premiums, but they would be less than current insurance company premiums. This would mean a healthier economy with more money in the pockets of businesses and working people.

The State of California recently concluded a 1.2 million-dollar study called the Health Care Options Project. (www.healthcareoptions.ca.gov) It concluded that by removing the insurance industry from the health care loop, Californians could save 7.6 billion dollars a year while insuring everyone with better services including long term care and full prescription drug coverage. As insurance would not be tied to employment, you could change jobs and still keep your same doctor.
Bodaken dismissed the study saying he disagreed with it and that the Blue Shield Foundation would produce its own study showing how his plan would work.

State Senator Sheila Kuehl will soon introduce legislation for the plan that saves Californians money and produces high quality health care for all.

More money for Blue Shield is not the only choice.

Don Bechler
Chair
Health Care For All
San Francisco Chapter
415-695-7891

Posted by pnhp at 10:19 AM | Permalink | Comments (0)

Authors of a new study published today on the Health Affairs Web site say that higher drug cost-sharing saves money for retiree health plans, but enrollees pay more; drug utilization isn't necessarily reduced. The authors conclude that policymakers should consider how copayments change use when designing a Medicare drug benefit. To view the article, go to www.healthaffairs.org/WebExclusives/Thomas_Web_Excl_120402.htm.

BETHESDA, Md.—Employer health plans that charge retirees higher copayments for retail pharmaceuticals saved themselves 18.7 percent per member on average in 2001, but their enrollees on average had 59.4 percent higher out-of-pocket costs ($389 versus $244), according to a new study published as a Health Affairs Web exclusive.

The study demonstrates the effects that plan design might have on costs and drug use under any Medicare prescription benefit, write authors Cindy Parks Thomas, Stanley S. Wallack and colleagues from Brandeis University’s Schneider Institute for Health Policy. The authors write that the study shows that higher copayments lead to the use of less-expensive drugs and fewer retail purchases, although they argue that Medicare should consider using copayment strategies in combination with other cost-containment mechanisms such as encouraging generics, mail-order delivery of prescriptions, prior authorization, and provider education.

The authors studied prescription drug claims made by more than 29,000 retirees age 65 and older enrolled in 96 employer plans managed by one pharmacy benefit management firm. They compared prescription drug use and costs in a number of plan designs, including those with multiple “tiers” of benefits and cost-sharing requirements.

They compared plans with cost sharing categorized as “more-aggressive” and “less-aggressive,” defined by whether they required an above- or below-average copayment for brand-name drugs, or whether they required coinsurance of more or less than 30 percent for brand-name drugs. The “more-aggressive” cost-sharing plans had average per-enrollee costs to the plan of $1,155 and average enrollee out-of-pocket costs of $389 in 2001. The “less-aggressive” plans had average per-enrollee plan costs of $1,421 and average enrollee out-of-pocket costs of $244 in 2001.

Enrollees in the more-aggressive plans had on average overall costs of $1,544 in 2001, compared to less-aggressive plans, which had fewer 30-day equivalent prescriptions and overall costs of $1,665 per enrollee. The study attributes half of the difference in costs to the higher cost-sharing in the more-aggressive plans, but says the greater use of generics, less expensive brands, and more mail-order delivery lowers the costs of drugs in those plans.

Across all the plan designs studied, average annual spending per enrollee was $1,571 in 2001, with average member out-of-pocket cost-sharing of 18 percent. The plans that had the highest member cost-sharing were the single-tiered plans with at least 50% member coinsurance for retail purchases, combined with mail order incentives, and the three-tier plans that charged between 10 percent and 40 percent member coinsurance, depending on the type of drug. Those plans had total member out-of-pocket cost sharing of 28 percent and 22 percent, respectively.

The study also found that enrollees are more likely to use generics when they fill their prescriptions at retail pharmacies under plans that have the greatest spread in copayments between brand-name and generic drugs. This is particularly true in plans that make use of coinsurance, which as a percentage of the total cost is variable based on the total price of the drug and not a flat copayment. For example, the authors found that in three-tier plans with a maximum 30 percent coinsurance for retail purchases and an actual copayment difference of $15 between generic and brand-name drugs, 44.5 percent of prescriptions were generic. In a three-tier plan with a $5 to $10 difference between tiers, only 36.1 percent were generic.

In addition, the study found that use of generic medications and use of mail order can save money both for enrollees, through lower copayments, and plans, through lower overall costs. The average mail-order price for all prescriptions was 16.4 percent less than retail. However, use of generics saved the most, with the average price of a generic prescription over 70 percent less than the average brand, at the pharmacy or through mail order.

The study can be read at www.healthaffairs.org/WebExclusives/Thomas_Web_Excl_120402.htm.

The research was funded by the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research.

Posted by pnhp at 11:19 AM | Permalink | Comments (0)

The 31st Constitutional Convention of the United Steelworkers of America (USWA) held in Las Vegas August 5-8, attended by 2,500 union leaders from across the US and Canada, was convened under the banner "Fighting to Win." It took up issues connected with collective bargaining, organizing, global justice and political activism. The convention adopted a special resolution calling for a new universal and comprehensive healthcare system. The resolution, titled "For a Single Payer Healthcare, Publicly-Funded, Not-for-Profit Health Plan" and passed as an "emergency measure," was referred to the convention by action of USWA Local 1375.

The resolution reads in part:

WHEREAS, every person residing or employed in the United States is entitled, as a matter of right, to accessible, affordable and quality health care; and

WHEREAS, this Union, the United Steelworkers of America recognizes that there is a growing crisis in health care in the United States of America manifested by massive layoffs, a steep increase in premiums, co-payments and deductibles, and the closing of many health care facilities serving low-to-middle income residents; and

WHEREAS, 44 million people in the United States have no health insurance coverage and that number is increasing rapidly; and

WHEREAS, 42 million people having only limited insurance are one catastrophic illness away from bankruptcy; and

WHEREAS, insured persons now commonly experience unacceptable and sometimes life-threatening delays in obtaining approval for needed health care services by private, for-profit health insurers; and

WHEREAS, it is estimated that the complex and redundant bureaucracy arising from the existence of multiple, for-profit insurance plans, each with its own distinct program of coverage and benefits, its own costly administrative and executive structure, and its own system of processing managed care approvals, and payments of benefits and/or reimbursements, wastes up to 30% of medical coverage premiums paid for by employers and private citizens; resources which otherwise could be used to provide benefits; and

WHEREAS, the bureaucratic structure and its inefficiencies distract health care providers from providing efficient and effective medical services to patients and places a drain on the financial resources of taxpayers; and

WHEREAS, this Union contends that a single-payer, publicly-funded, not-for-profit health plan will: eliminate the redundant bureaucracy caused by numerous insurers; greatly reduce administrative costs associated with providing medical care; free-up additional financial resources; allow medical providers to focus their efforts on providing quality care; and reduce the cost of health care coverage for residents and employers; and

WHEREAS, this resolution constitutes an emergency measure providing for the immediate preservation of the public health; now therefore,

BE IT RESOLVED BY THE UNITED STEELWORKERS OF AMERICA:

Section 1. That the Delegates to the Thirty-First Constitutional Convention of the United Steelworkers of America urges the United States House and Senate to commit to enact a comprehensive, publicly funded, not-for-profit health insurance program covering: (a) all residents of the United States of America as well as all dependents of United States residents, whether residing within the United States or elsewhere; and (b) all persons employed in the United States, regardless of residence within or outside of the United States, as well as their dependents.

Section 2. That this Thirty-First Constitutional Convention urges the prompt passage of Single Payer Health Insurance System so that upon its effective date:

i. Health insurance will be provided to all persons employed in the United States and their dependents by or through their federal, state and local public and private employers, including all health insurance previously provided by the federal, state and local government to its employees, thereby relieving these employers of the cost and administrative burden of providing health insurance coverage; and        ii. Every person will be covered by one uniform program of health insurance benefits, including prescription drug coverage, dental care, vision care, long-term care and coverage for mental illness on full parity with coverage for all other types of illnesses; and        iii. A Commission will be created, as an independent agency of the federal government, to implement and administer the Single Payer Health Insurance program; and        iv. The Single Payer Health Insurance benefit program will be designed and maintained so as to guarantee health care services of excellent quality, timely delivered and accessible to all; full support for ongoing medical research, medical education and training; full choice of providers; and access to comprehensive, preventive and long-term care; and     v. All federal, state and local funds allocated for health care purposes by Medicare, Medicaid, Veterans Administration, and other programs will be directed to the Single Payer Health Insurance benefit program, after obtaining the necessary waivers; and        vi. Any person who while covered by the Single Payer Health Insurance benefit program requires health care services anywhere in the world will be entitled to Single Payer Health Insurance program benefits to pay for such services to the extent payment has not otherwise been provided; and        vii. Any resident displaced from employment by the private health insurance industry in this United States as a direct result of the enactment of Single Payer Health Insurance benefit program will be eligible to receive, at state expense, retraining and temporary financial assistance to facilitate reemployment without significant loss of income, and will receive preference for hiring for employment by the Single Payer Health Insurance benefit program Commission in any position for which the displaced resident is qualified; and viii. Single Payer Health Insurance benefit program will be funded by utilizing federal, state and local monies that currently are used to fund existing federal, state and local health care programs, and any additional funding mechanism deemed necessary to ensure that Single Payer Health Insurance benefit program is fully funded with adequate reserves.

Section 3. That the Secretary-Treasurer of the United Steelworkers of America is hereby requested to forward a copy of this resolution to the members of the United States House and Senate.

Posted by pnhp at 11:12 AM | Permalink | Comments (1)

Orange County Register
December 1, 2002
Commentary: National health insurance may be our only solution
by Michael T. Kennedy, MD, FACS

Don Hull's letter, "Universal coverage is anything but" [Nov 22], attacks the National Academy of Sciences for suggesting that the Bush administration should "test possible solutions, including universal insurance coverage." Hull equates universal health insurance, a single-payer system similar to the British National Health System, to the Soviet Union and Cuba, both communist dictatorships.

This is rhetorical hysteria.

The situation in California is at crisis level. Los Angeles County is planning to close major hospitals including Harbor General and Rancho Los Amigos, the latter the premier rehabilitation facility in the world.

Orange County hospitals are burdened with thousands of illegal, uninsured immigrants seeking care, but we can't turn them away from emergency rooms. They are getting treatment, and doctors and hospitals are paying for it out of the decreasing margins left over from managed care. The system for indigent care is overwhelmed. HMOs are "cherry-picking" healthy subscribers and providers (doctors and hospitals) are being squeezed to the point of insolvency. This can't go on much longer.

Free markets depend on information. The transaction has to be "transparent" so both the buyer and seller know the same facts. This is very difficult to accomplish in health care. Healthy subscribers like HMOs' lower premiums but when they get sick, it is too late to change. We have an aging population and Medicare is cutting back on reimbursement. No "fat" is left in the system. There is, however, an enormous amount of administrative spending in the current system. There are also many perverse incentives to "game the system" as shown in the Tenet Hospital scandal in northern California.

It may well be that a universal health plan, covering everyone regardless of ability to pay, could be funded out of the total current expenditure on the present system, which has so many distortions. Our own system is unstable and it will not be long before that is apparent even to Hull who probably believes himself to be safe.

Michael T. Kennedy Mission Viejo

Dr. Kennedy is past president the Orange County Medical Association and a past co-director of the Mission Hospital Trauma Center.

http://www2.ocregister.com/ocrweb/ocr/article.do?id=13884&year=2002&month=12&day=3

Comment: Noteworthy about this commentary is that Mike Kennedy, a personal friend, is predominantly a political conservative, and the Orange County Register is a libertarian newspaper. But an objective assessment of the factual status of our health care system, and an objective assessment of the application of health policy science will go a long way toward achieving mutual agreement on the desired model of health care reform. As Mike says, the situation in California is at a crisis level. It is time for all of us to work together on a solution.

Posted by pnhp at 11:10 AM | Permalink | Comments (0)

USA TODAY, December 4, 2002

By Julie Appleby
    
       In a break with many other insurers, the head of Blue Shield of California is calling for universal health care, starting with Californians.

       "Some of my peers in the industry may be disappointed with this approach," CEO Bruce Bodaken told the Commonwealth Club in San Francisco Tuesday. "We are willing to take these risks for a simple reason: The current system and its underlying economics are unsustainable."

       Bodaken heads one of the state's leading health insurers, a not-for-profit entity with 2.6 million enrollees. His talk comes as health care costs are rising at their fastest clip in a decade, as more Americans fear losing coverage and as managed care is no longer seen as the answer to the problems.

       Political interest in reforming health care has also revived: Former vice president Al Gore is calling for a single-payer system, several presidential hopefuls are touting their plans for universal coverage and the Bush administration is pushing tax credits and an expansion of community health clinics to help the uninsured.

       Still, many lawmakers consider it politically dangerous to embrace a major overhaul. Voters in Oregon last month rejected a plan to give all state residents health care, paid for with tax increases.

       Bodaken's plan is not an overhaul. Instead, he suggests building on the current system, by requiring employers to offer coverage or pay into a fund. In turn, individuals would also be required to buy coverage and those who can't afford it would get government subsidies.

       State and federal health programs would be expanded to cover more low-income residents. Some kind of new tax would help pay for it all.
      
       "Every one of us will have to participate and in some cases make a sacrifice for the good of the whole," says Bodaken, who sees such efforts starting in the states and eventually going national.

       Critics say a plan like Bodaken's won't solve the system's many problems because it does not remove insurance companies from the equation.

       "He's got the right diagnosis but the wrong treatment," says Quentin Young, national coordinator for Physicians for a National Health Program, a group that supports a single-payer-type plan similar to Medicare. "We need to end the profit-motivated distortions in our system."

       Under a single-payer plan, insurance companies, essentially, would be out of business. Bodaken's plan, by contrast, could help insurers by requiring everyone to carry insurance. Observers say it is hard to evaluate the plan because many details are unclear. Still, many welcome the debate and say it is significant that a managed care insurer is calling for reform.

       Karen Ignagni of the American Association of Health Plans says the industry wants universal coverage. "Universal coverage doesn't mean government takeover of the system," she says. "Our community wants to play a major role in working with Congress and the states."

http://www.usatoday.com/money/industries/health/2002-12-03-universal_x.htm

Posted by pnhp at 10:05 AM | Permalink | Comments (0)

The Mounting Crisis in Health Care
Universal medical coverage needs universal commitment

Bruce G. Bodaken, CEO, Blue Shield of California

Hardly a day goes by that we don't hear a story about turmoil in California's health-care system: the collapsing trauma network in Los Angeles; hospital overcharges in Redding; bankrupt medical groups in San Jose or nurses on strike in the East Bay. Health-care costs are rising at astronomical rates, thousands are losing their insurance and the state government is too broke to adequately fund health-care programs for the poor.

According to the U.S. Census Bureau, one in five Californians -- more than 6 million in all -- are uninsured. They include workers in small businesses who aren't offered insurance and can't afford to buy it on their own; and people who are eligible for public programs such as Medi-Cal and Healthy Families but don't know how to navigate the bureaucracy. A surprising number are wealthy and healthy enough to afford insurance but choose not to buy it.

With a weak economy, rapidly escalating costs and an aging population needing more services, a deepening crisis is inevitable. Something must be done.

What are the consequences of not having insurance? You're more likely to live sicker and die poorer. Each year, 18,000 people die unnecessarily because they lacked health insurance, and uninsured infants are 50 percent less likely to survive than newborns with insurance. If you're uninsured, you probably ignore the first symptoms of an illness and wait until you're really sick before seeing a doctor. More often than not, you'll go straight to the emergency room, a costly and impersonal place to receive basic medical care.

Meanwhile, well-off people without any symptoms are spending $900 for full- body scans they don't need. When the scan finds something ambiguous, they spend thousands more getting additional tests that prove they're healthy after all.

This unequal and inefficient system must be changed. A new model should be based upon individual, corporate and societal responsibility.

Here's what we should do:

-- Build upon the existing employer-based system: Preserve a paradigm that has successfully insured a majority of American workers and their families for six decades. Require employers, except smaller companies, to offer coverage or contribute an equivalent amount toward an essential benefit package for each employee.

-- Promote state programs: Enroll every eligible Californian in Medi-Cal or Healthy Families. The state and private sector should work together on creative and effective marketing and outreach strategies.

-- Require coverage: Require those who can afford insurance to buy it. Others would be subsidized based upon documented need.

-- Define essentials: Provide an essential benefits package, designed by independent medical professionals, that would guarantee preventive care, physician services, hospital care and prescription drugs.

-- Encourage savings: Achieve savings through expanded preventive care, earlier treatment of the formerly uninsured, reduced use of emergency rooms and more secure financing.

-- Establish tax-based funding: Supplement the additional business and individual contributions to the insurance pool with a modest, broad-based tax or fee as needed.

http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2002/12/02/ED52155.DTL

Comment: To say that there is a tide of support for an employer mandate for health care coverage with a public program for low-income and uninsurable individuals would be a gross understatement. That tide is a tsunami that will soon engulf California. The employer mandate is now supported by politicians, business, labor, organized medicine, hospital administrators, consumer organizations, and the insurance industry. In March, the RWJ Covering the Uninsured campaign will unleash efforts to align public opinion in support of this model of reform. It is likely that this year the employer mandate will cross the threshold of political feasibility.

California will serve as a testing ground for political solutions for our health care crisis. Sen. Jackie Speier will be introducing legislation in support of the employer mandate/public insurance model, and Sen. Sheila Kuehl will be introducing legislation supporting a single payer model. Both are vast improvements over our current fragmented, wasteful and inequitable system. But there are major differences.

The single payer model has the advantage of reducing administrative waste, allowing more funds to be directed towards a more equitable system of health care. It would provide economic mechanisms to slow the escalation of health care costs. The employer mandate/public insurance model would perpetuate both administrative excesses and the inequities of a system in which multiple health plans game the system to shift costs. And the public insurance component inevitably would be underfunded as it would be perceived to be a "welfare program." But the employer mandate/public insurance model has one overwhelming advantage: political feasibility.

Our task is to make every effort to be certain that the public understands all options available. The other vested interests understand the issues and realize that the employer mandate/public insurance model comes closest to meeting their collective needs. The task to educate the public will be monumental. But the Canadian Romanow study confirms that a public that has decades of experience with a single public model emphatically rejects the suggestion that our system of private and public health plans would be preferred.

For the democratic process to function properly, it is essential that we have an informed electorate. Since the vested interests profit by disinformation, it is our task to be sure that the public really understands all options. Immediate initiation of massive grassroots coalition efforts is mandatory. The alternative is a system, by default, that primarily caters to the vested interests of those with money and power, relegating patients to a secondary position.

Posted by pnhp at 10:36 AM | Permalink | Comments (1)

Measure 23 (Health Care for All) died an ignominious death on Nov. 5, but the health care crisis is still with us. The Oregon Health Plan's future is uncertain and nearly half a million Oregonians are uninsured, including many low-wage workers. Many more are underinsured and struggling to pay exorbitant premiums. On a national level, moderate Sen. John Breaux of Louisiana declares that U.S. health care is "collapsing around us". The horror stories that volunteers for Measure 23 heard during the campaign are remembered. But where do we go from here?

Americans spend far more on health care than other developed countries. Yet, the U.S. ranks only thirty-seventh in quality, according to the World Health Organization. Employer-based health care greatly increases labor costs, holds down wages, and keeps employees tied to particular jobs. U.S. health care costs are distributed through premiums, employer benefits, out-of-pocket expenses, and TAXES, so that the full cost is not appreciated. Our taxes pay for 60 percent of U.S. health care, while the Canadian government pays for 70 percent of Canadian health care. We are paying for a national health care system, but not receiving it.

Congress seems committed to "incrementalism" - just covering children, the needy, prescription drugs for the elderly, etc. From a cost-control viewpoint alone, two things are wrong with our piecemeal approach. First, as long as the uninsured are increasing and not getting preventive care, rising costs will be shifted to the insured. Restricting health care has contributed to the double-digit inflation in health care premiums. In any insurance plan, the larger the risk pool, the smaller the cost for the individual. Therefore, cost-effective health care will start with universal coverage. Second, the huge administrative costs of the insurance companies must be eliminated. Health care as a public service does not fit a profit-driven system. Administrative costs of a single-payer (government-insured) health care system are typically one-fifth that of a U.S. insurance company. Additionally, a national plan (as opposed to state-wide) eases the burden on small states and eliminates the migration argument.

The General Accounting Office has determined that single-payer national health care is the most cost-effective method of health care delivery that maintains providers in the private sector. It is no stranger to the U.S. Medicare was originally conceived as a single-payer system but is presently filtered through many insurance companies, adding to the complexity, expense, and diminishing coverage.

While the benefits of national health insurance are clear, many obstacles stand in the way. Americans must be persuaded that under such a system, provider choice would expand, not diminish, and that quality need not be sacrificed. The feeling that government cannot properly administer any public service is an American conviction, in spite of the popularity of Social Security, Medicare, Medicaid, an excellent military, and the fact that over 90% of Americans are publicly educated.

Where does health care reform go from here? A simplified state-wide initiative might be attempted to keep the issue alive. More Americans must be registered to vote so that they can support reform-minded candidates. Support the Wyden-Hatch Act and other legislation that will be introduced in 2003. In the meantime, let's keep talking.

(Roberta Palmer, M.D., of Tigard is a member of Physicians for a National Health Program.)

Posted by pnhp at 09:08 AM | Permalink | Comments (0)

Health care reform is back in the news. This time, does it stand a chance?

By Jonathan Cohn, 12/1/2002

WHEN SENATOR EDWARD Kennedy announced on Nov. 21 that he would soon propose a plan for universal health insurance, it barely qualified as news. Kennedy has been a member of Congress for 40 years now, and in that time he's introduced major health care bills at least a dozen, maybe two dozen times. But for once, Kennedy's timing seemed exquisite. In the past, the senator has been a lonely champion of health care reform, fighting not only Republicans but even more cautious members of his own party. This time around, Kennedy has company in his crusade. And lots of it.

Just days before Kennedy made his announcement, Al Gore surprised reporters with his announcement that he will call for the creation of a ''single-payer'' health insurance system in the United States - that is, a system in which the government provides every citizen with health insurance directly, just as it does in Canada. Almost immediately, two of Gore's would-be rivals for the 2004 Democratic presidential nomination, Senators John Edwards and John Kerry, indicated they'd soon be unveiling health care plans of their own. Assuming all three men make good on their promises, they'll be following the lead of a fourth Democratic presidential contender, Vermont Governor Howard Dean, who long ago made universal health insurance the centerpiece of his upstart candidacy.

And Democrats running for president aren't the only ones talking about big changes in health care. The National Academy of Sciences has placed a starkly worded report on the desk of President Bush. ''The American health care system is confronting a crisis,'' it reads. ''The health care delivery system is incapable of meeting the present, let alone the future, needs of the American public.'' The academy went on to recommend that the federal government allow a handful of states to experiment with different schemes for achieving universal coverage, a message the Bush administration said it would take to heart. And while Bush doesn't exactly have the budget space to enact a major health reform right now - frittering away $1.7 trillion on a tax cut for the wealthy will do that - he has been talking up a more modest initiative to help the uninsured buy coverage for themselves.

Feel like you've heard this all before? That's because you have. In the early 1990s, as health care costs skyrocketed and a deep recession drove up unemployment, large numbers of Americans began to fear losing their insurance coverage and having to face serious medical bills, much as they do today. Panels of experts began churning out dire warnings of systemwide collapse and, before long, health care reform was the dominant topic in politics. During the 1992 campaign, the popularity of Bill Clinton's health care pitch even forced the incumbent president, Republican George H.W. Bush, to craft a modest reform package similar in broad outlines to what his son offers today.

Of course, all the talk about health care reform in the early 1990s didn't exactly make it happen. On the contrary, in 1994 Clinton's ambitious health care proposal died an ignominious death: Even though the Democrats controlled both the House and the Senate, the plan never came up for a vote on the floor of either chamber. Ultimately, it unleashed such furious political opposition that the Democrats lost control of the House for the first time in a generation. So while it seems pretty obvious that another national dialogue about health care is beginning, the real question is where that discussion will go. Will it produce meaningful change? Or will it produce exactly what the last great health care debate produced - namely, nothing?

Certainly, there are reasons to doubt that large scale health care reform will take place soon. A major reason that the Clinton plan ran afoul of public opinion was that substantially expanding the reach of health insurance coverage inevitably requires substantially expanding the reach of government. The voters were pretty ambivalent about that prospect then, and they still are now. What's more, you can bet the special interests who fought reform so vigorously in the 1990s - particularly the small business lobby and portions of the insurance industry - will do so again.

But even if those conditions remain largely the same, one key barrier to reform may be gone: the sense among middle-class Americans that their current insurance policies are sacrosanct. If you remember the fight over the Clinton health care plan, then you probably remember the ''Harry and Louise'' ads on television. Those spots featured a middle-class couple sitting around their kitchen table, purportedly reading aloud from the Clinton plan and recoiling at its provisions. As Harry and Louise explained it, under the Clinton plan Americans would lose their choice of doctor, their access to life-saving treatments, and so on. The advertisements echoed what would become the main line of attack against the Clinton plan: that middle-class Americans stood to lose more from government intervention in health care than they stood to gain.

Such an argument is unlikely to be so persuasive today. When government reform failed in 1994, employers took it upon themselves to restrain costs through managed care - a method that, although effective, rankled most consumers. Suddenly, all of the dire predictions of Harry and Louise were coming true anyway, even without the dreaded Clinton plan. Health maintenance organizations and other forms of managed care limited patients to selected groups of physicians, second-guessed treatment decisions, and created longer waits for those treatments that were approved. Whether or not these changes were necessary for the sake of containing costs, the fact is they made the status quo a lot less appealing to the average American. According to the Harris Poll, for example, the number of people who said health insurance companies do a ''bad job'' of serving consumers jumped from 47 percent to 57 percent from 1998 to 2001 alone. That's one reason regulating HMOs, a cause that burst onto the scene in the mid-1990s, became so popular so quickly. It's also one reason that enthusiasm for a total overhaul of health care has quietly crept back to its pre-1992 levels.

Another traditional obstacle to health care reform has been the cost. Any successful program to extend health coverage to the uninsured is going to require raising taxes, and one might expect voters to resist, even if it's just a matter of redirecting money they'd be spending on insurance premiums anyway.

But will they resist? Here is where today's reformers can unleash some scare tactics of their own, thanks to another side-effect of the managed care revolution. During the late 1990s, as insurance companies slashed the money they paid doctors and hospitals, the providers of health care responded by downsizing and making their operations more efficient. They largely succeeded - it's one reason hospitals like Beth Israel Deaconess and Massachusetts General, which were in so much financial trouble just a few years ago, are climbing back into the black - but only by compromising their ability to deal with surges of patients. The most visible result of this shift has been a nationwide epidemic of overcrowded emergency rooms, a crisis Boston knows only too well. As recently reported in the Globe, Massachusetts ERs are now diverting ambulance traffic twice as often as they did just two years ago. And once patients do make it into the ER, they must frequently wait hours - even days - before getting admitted.

Stories like this scare people, as well they should. And because everybody, not just the poor, might someday need care in an emergency room, concern about ER crowding can motivate otherwise complacent, relatively comfortable voters into supporting expensive health care initiatives. Just consider what happened in Southern California this Election Day, where voters in Los Angeles - cradle of the antitax movement - overwhelmingly approved a property tax increase in order to support local trauma care. A major reason they did so was a series of television ads portraying paramedics desperately seeking emergency rooms that would accept their patients. The ads were dramatizations, but they weren't fiction: In LA, emergency rooms now divert ambulance traffic 40 percent of the time.

To be sure, it's a long way from enacting a local ER tax to making health insurance a right of citizenship, as many reformers now propose to do. And as if to demonstrate the extent of that distance, on the same day voters in Los Angeles approved their new property tax the voters in Oregon, about as progressive a state as you'll find on health care issues, overwhelmingly rejected a ballot initiative that would have required the creation of a universal health care program in the state.

But today's reformers have learned a key tactical lesson from Clinton: don't try to reinvent the entire health care system at once. That's why Howard Dean, who once proposed a Clinton-like scheme for Vermont, has said he'll work on insuring children up to the age of 22 first and worry about the adults afterward. Ted Kennedy may have a reputation as a radical, but his plan actually calls for leaving our current employer-based system intact. He'd simply require that businesses give their workers benefits and cover three-quarters of the cost themselves; employees would pick up the rest of the bill, with government subsidizing low-income workers who can't afford their share of the premiums. Then there is the National Academy of Sciences approach to health reform: letting a few states experiment with universal coverage until somebody gets it right.

Al Gore's proposal would appear to be the odd one out: The adoption of Canadian-style national health insurance would represent a sweeping change of Clintonlike proportions. But Gore may have learned a key lesson from Clinton, too. Clinton's determination to produce a workable compromise ultimately produced a convoluted scheme that, however elegant on paper, was impossible to defend from Harry and Louise's kitchen table jabs. Gore, by contrast, can describe his plan with one simple slogan, ''Medicare for All,'' thereby linking it to one of the most popular and successful government programs of all time.

Admittedly, it will take more than simplicity to sell large-scale health care reform right now. If Congress can't even pass HMO reform, a relatively modest measure that would merely regulate the way insurance companies make decisions about treatments, the prospects for more sweeping measures would seem pretty slim. But the plight of the uninsured and the anxieties of the currently insured are getting worse, and this means the political appetite for health care reform is likely to increase. Ted Kennedy obviously thinks it will. And judging by all his newfound political soulmates, he's not alone.

This story ran on page D1 of the Boston Globe on 12/1/2002.
© Copyright 2002 Globe Newspaper Company.

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By NUPGE Research

Since the beginning of our campaign to protect and build Canada's Medicare, the National Union of Public and General Employees has recommended that the different levels of government work together to reach ten objectives. We believe that these ten objectives are not only about the health of Canadians, they are also about the economic health ofCanada. Achieving these ten objectives is the best way to ensure that we have a sustainable health care system that reflects Canadian values and lives up to Canadian standards for efficiency. We also believe that these ten objectives draw on the courage of the original vision put forward by the pioneers ofCanada's Medicare and fulfill that vision by restoring, rethinking, and reinvesting in public Medicare and the people who provide health services. This report card is intended to evaluate how well the final report of the Romanow Commission stacks up against the National Union's ten objectives.

Objective 1

Adequate and stable public funding
Romanow Report Grade: A

The report recommends the federal government provide "adequate, predictable, and stable public funding for Medicare." To do so, the report recommends a multi-billion dollar injection of federal funds until it reaches a 25% minimum cash floor of Canada Health Act insured services - $6.5 billion more per year by 2006 - $3.5 Billion in 03/04, $5 billion in 04/05, and $6.5 Billion in 05/06. NUPGE, the CLC, other unions and many of our health coalition partners have called on the federal government to increase its share of health funding to 25% of publicly insured services. The Romanow report clearly reaches this benchmark.

As equally important as proposing increased federal funds, the report recommends that the new federal cash be used to "buy change" by attaching strings (through earmarked funding initiatives) to the new funds. In addition, the report recommends that the CHST be abandoned and replaced with a separate fund for health care transfers to the provinces (called the Canada Health Transfer) with a built-in escalator provision so that federal funding would keep pace with economic growth. This is the kind of accountability and transparency that's necessary to ensure that any new health dollars actually go to health care services rather than tax cuts or other areas and it is something the labour movement has called for over the last 8 years. 

The Romanow report is much better that the Kirby report when it comes to increased public funding for Medicare. Kirby proposed what amounts to a permanent user fee, payable by all tax payers. Kirby's proposal would not raise enough funds and it does not meet the test of fairness.

While we could argue that Medicare needs more money than what is being proposed, what is being offered is significant (particularly if the federal government gets to the 25% minimum, using the existing progressive income tax system and its revenues, with a built-in escalator) and this section of the report is positive and comes very close to meeting our Objective.

Objective 2

Never for profit
Romanow Report Grade: B

The report states that: 'Medicare is a moral enterprise, not a commercial venture. Medicare is a right of citizenship ... It is a far greater perversion of Canadian values to accept a system where money, rather than need, determines who gets access to care. " The report concludes that private, for-profit health care runs the risk of being more expensive, providing worse care and undermining the value of fairness.

The report clearly states that Romanow challenged those advocating private sector solutions to provide the evidence but that evidence was not forthcoming. The answer to Canadian health needs, the report concludes, does not lie in the private sector but in a better funded public system.

The Romanow report also recommends decisive action to curb the growing number of private for-profit MRI and other diagnostic services clinics, concluding that these private clinics lead to queue-jumping and this violates the principles of the Canada Health Act. The report recommends that diagnostic services be explicitly included under the definition of insured services under the Canada Health Act. The report recommends that there be no user fees, facility fees or extra billing for MRIs and CT scans; thus, making it illegal for anyone to be charged an out-of-pocket fee for these services. The report recommends thatOttawapenalize any provinces that allow private delivery of diagnostic services. The report also states that the current status of injured workers (WCB claims) getting preferred access to care and being sent to private clinics violates the principle of equal access. Further, the report proposes a Diagnostic Services Fund of $1.5 billion over 2 years to improve wait times.

The report looks at Public-Private Partnerships and essentially concludes that they're not a good idea and will end up costing taxpayers more than if the government had simply done the job itself in the first place. The report also notes that these arrangements can have the effect of hospital bed closures and a reduction in staffing levels.

The Romanow report also recommends that user fees, medical savings accounts, deductibles and tax-based co-payments continue to be banned by the CHA.

Clearly, this is much better than the Kirby report which has no problem with further commercialization, private for-profit ownership and delivery.

However, the report does have a major weakness on the issue of privatization. It offers reasons and suggests there is evidence that contracting-out of non-medical services such as food preparation, laundry, maintenance and cleaning is okay. This is not the right thing to recommend or the smart thing to recommend and therefore the report, on this point, is extremely disappointing.

Further, while the report gives strong rationale for opposing private for-profit care, the report is missing a specific recommendation of a specific mechanism for banning private, for-profit delivery of health services. 

In addition, while the report is critical of P3s it stops short of recommending they be banned completely and even suggests that they might be useful in non-direct health areas such as "health information systems."

This section of the report went far, but could have and should have gone even further. In any health care institution, germ-free environments, properly sterilized laundry and food safety are critical to the well-being of patients - we can't afford to cut corners with for-profit laundry, dietary and maintenance services. The report should have said this but it didn't. Therefore, this section of the report does not completely meet our Objective.

Objective 3

Debunk private health care myths
Romanow Report Grade: A

The report is an eloquent defence of public Medicare. It offers unqualified support for the principles underlying public Medicare. It dismisses the myth that public Medicare is on the brink of collapse. It debunks the myth that public Medicare is unsustainable or unaffordable. It also challenges the myth that private, for-profit care is more efficient, would shorten waiting lines, and provides better care (except when it comes to support services and this is a problem with the report). It also concludes that 'innovations' such as user fees, medical savings accounts, P3s etc. are nothing more than standard right-wing nostrums that will do nothing to improve Medicare.

This part of the report is very positive and meets our Objective.
 

Objective 4

A comprehensive national health human resources strategy
Romanow Report Grade: B

The report suggests the need to look at changing the scopes and patterns of practice of health providers.
 
The report argues for a national database to analyze relevant human resource information, and track and forecast trends.

It also suggests that governments stop recruiting health care workers from third world countries.

The report calls for a Rural and Remote Access Fund ($1.5 Billion over 2 years) to attract and retain health care providers, including opportunities for health professionals to train and gain experience.
 
There are not enough substantial recommendations on this subject - i.e. it does not make specific suggestions for training and upgrading skills of existing health professionals and other workers. Most of the details of a national health human resources strategy are left to be developed by a new Health Council of Canada. We were hoping for more substantive recommendations and a national fund for a human resource strategy. We were also looking for a proposal to promote and market the various health professions.
 
On this subject, the Romanow report only partially addresses the Objective we set out. 
 

Objective 5

Primary Care Reform - Develop a system of blended care
Romanow Report Grade: A

The report recommends a common national platform for primary care reform.

It recommends a $2.5 billion investment over 2 years through a Primary Health Care Transfer in order to remove barriers to change and kick-start reform. Of course, service delivery is provincial jurisdiction, so Romanow recommends the federal government link the new funding to provincial pursuit of the community clinic model.

The changes it proposes include: full-service community health clinics where patients can access a team of health professionals 24-7and receive everything from a doctor's prescription to nutritional advice to physiotherapy and psychiatric help.

There is also an emphasis on the need for cultural diversity and removing language barriers to improve access to care.

The report also talks about the need to put more emphasis on wellness and disease prevention programs - tobacco, obesity and physical activity are good choices to start with for health promotion.

In some ways this section of the Romanow report is similar to Kirby's proposal of creating primary-care groups of different types of health-care providers. However, Romanow's recommendation is better in that it calls on the federal government to use any new money to 'buy the changes needed in primary care reform' and it talks about wellness and prevention programs being critical to good health.

The focus on primary care reform, integrated with health promotion and disease prevention is long over-due. This section of the report and its related recommendations are very positive and come very close to meeting our Objective.

Objective 6
Add home care to the Canada Health Act
Romanow Report Grade: B

The report recommends that Ottawa kick-start a process (and provide the foundation for) a national home care program by covering all priority home care services - i.e. intervention services, home mental health services, palliative care, post-acute home care - through a Home Care Transfer of $2 billion over 2 years.

It is not clear what the report suggests should be done with home support / personal support services. It has no specific recommendation on bringing these services under the CHA so we must assume it is okay with those services, for the most part, being left out of the Act and therefore becoming out-of-pocket expenses for all intents and purposes. This would not be the right thing to do or the smart thing to do. These are services that allow people to live with dignity in their own homes. That both improves care and saves money by keeping people out of hospitals.

The Kirby report called for a national home care program that would cover only those just released from hospital or those near death.

This part of the report does not go all the way and recommend a new national program immediately, and not mentioning home support services is disappointing, but it does propose a good step forward in the direction of including all home care services under the CHA. It doesn't completely meet our Objective but it brings us a closer to a national home care program. 

Objective 7
Add long term care to the Canada Health Act
Romanow Report Grade: D

The Romanow report is a dismal failure on this Objective. The report does not make any recommendations at all for institutional care.

It assumes, for the most part, that through home care reform and increased coverage of acute and palliative home care services under the CHA, you would be able reduce the demand for beds in long-term care institutions.

The report does not recommend national standards for long-term institutions and it does not recommend new immediate public funding for long-term care.

The total lack of recommendations in this area is clearly a major win for the huge private corporations involved in the long-term care industry i.e. Extendicare.

 
Objective 8
Add a national pharmacare program to the Canada Health Act
Romanow Report Grade: A-

The report concludes that the short term priority should be to provide public funding for "catastrophic drug costs" with the Canada Health Act eventually covering the cost of prescription drugs.

It recommends the establishment of a National Drug Agency and a National Drug Formulary as a national strategy for dealing with soaring drug costs, providing comprehensive coverage and objective and accurate information on drugs.

The Romanow report also calls for a review of current drug patent laws inCanada.

The Romanow recommendation is better than Kirby's proposal which calls for public coverage after $5,000 and does nothing to address the root causes of soaring drug costs (patent law). 

This recommendation falls short of our Objective of a National Pharmacare Program but it offers a huge step in the right direction, especially on the recommendation to review patent laws. 

Objective 9
Exclude health services from all international trade deals
Romanow Report Grade: A

The Romanow report offers a strong message on this issue. The report issues a 'warning flag' on globalization and trade deals and their impact on the future expansion of public health care.

It recommends that governments must not delete from trade deals any of the current protections and exemptions for health care and it states thatCanadashould work with other nations to protect public health care from trade agreements.

It also states that any future efforts to expand public Medicare must also be protected from trade deals. 

It also states that the right to regulate health policy should not be subject to claims from foreign companies.

The Romanow recommendation is better than the Kirby report which ignores altogether the risks posed by NAFTA and other trade agreements that further privatization of health services would open the door to US and other foreign corporations to penetrate our Medicare and take over its services.

The report could have called for a renegotiation of trade deals which would provide even stronger protection for public health services. There should have been a recommendation that the Canadian government take TeleHealth technology off any trade negotiation table.

On the whole, the Romanow report is strong on this subject and comes very close to meeting our Objective.

 
Objective 10
Women's equality in health care
Romanow Report Grade: A

The report recommends that governments provide some kind of financial aid to those (overwhelmingly women) who have to stay at home to care for sick, elderly or disabled relatives. On principle this is an excellent recommendation and it takes us into any area governments have not yet ventured. Of course, the devil will be in the details with respect to how the assistance is provided - likely through the EI system

The recommendation of increased public funding and reversing the trend of privatization is also very helpful for health care workers the majority of whom are women. Contradicting this, however, is the section of the report that offers reasons for contracting-out support services. This would unevenly affect women workers and so this aspect of the report could have been better.

The report does not offer enough to address the unique health needs of women and related access issues.

The Romanow recommendation is much better than the Kirby report which ignores the uneven burden faced by women when it comes to unpaid care giving in the home. Further the Kirby endorsement of private for-profit ownership of facilities and services would actually exacerbate the uneven burden and unequal access to health services faced by women.

The report goes further than any other to address the uneven burden faced by unpaid care-givers (mostly women) and comes close to meeting our Objective.

Other Important Recommendations

· A new Canadian Health Covenant is proposed to express Canadians collective vision for health care and updating the Canada Health Act.

· A New Health Council of Canada to foster collaboration amongst governments and stakeholders.

· The report recommends that a 6th principle of "accountability" be added to the Canada Health Act.

 
FOR MORE INFORMATION:
Contact Mike Luffat
Phone: 613-228-9800
Fax: 613-228-9801
Email: mluff@nupge.ca
Visit:   www.nupge.ca
www.savemedicare.com  
www.youthformedicare.ca

Posted by pnhp at 09:42 AM | Permalink | Comments (1)