News

American Journal of Public Health
March, 2002
By Brady G. S. Case, AB, David U. Himmelstein, MD and Steffie Woolhandler, MD, MPH

"Conclusions. Health care personnel are losing health insurance coverage more rapidly than are other workers. Increasingly, the health care sector is consigning its own workers and their children to the ranks of the uninsured."

http://www.ajph.org/cgi/content/abstract/92/3/404

Los Angeles Times February 28, 2002 "More Health-Care Aides Lack Insurance, Study Finds" By Sufiya Abdur-Rahman

Drew Altman, president of Kaiser Family Foundation:

"You'd like the health-care industry to practice what it preaches, but the health-care industry is just like any other industry when it comes to low-wage workers."

Walter Zelman, president of the California Assn. of Health Plans:

"It's not any worse for a low-wage employee in a restaurant to be uninsured than a low-wage employee in a nursing home to be uninsured. They have the same family, the same risks and it's unfortunate for anyone to be uninsured."

David Himmelstein, M.D., Harvard professor and co-author of the study:

"There's something particularly offensive in saying to a woman who's working for a hospital that if you get sick or your kids get sick, you're not going to be able to get the care you need."

http://www.latimes.com/news/local/la-000015228feb28.story?coll+la%2Dheadlines%2Dcalifornia

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Health Affairs
February 27 2002
by Mary A. Laschober, Michelle Kitchman, Patricia Neuman, and Allison A. Strabic

"By fall 1999, 38 percent of beneficiaries lacked drug coverage, based on point-in-time estimates. This is much higher than previous estimates that measured beneficiaries' drug coverage at any time during the calendar year. Many of Medicare's most vulnerable beneficiaries-rural (50 percent), near-poor (44 percent), and oldest old (45 percent)-were most likely to lack drug coverage in the fall of 1999."

"With increasingly unaffordable premiums, the Medigap market is unlikely to absorb the recent and serious declines in Medicare HMO availability. It is also improbable that employer retiree plans or Medicaid will pick up the slack. Numerous studies show trends in declining retiree coverage. Although the MCBS data presented in this paper suggest that employer-sponsored coverage was relatively stable during 1996-1999, declines in retiree coverage are expected in the future. Medicaid will likely remain a critical source of supplemental coverage for the lowest-income beneficiaries but is unlikely to help middle- and higher-income beneficiaries, who may lose coverage from other sources."

"This uncertainty places even greater pressure on policymakers to add a prescription drug benefit to Medicare."

http://www.healthaffairs.org/WebExclusives/Laschober_Web_Excl_022702.htm

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

House Ways and Means Subcommittee on Health

February 13, 2002

Excerpts from the written testimony of Jonathan Gruber, Ph.D., Professor of Economics at Massachusetts Institute of Technology:

"The results that I discuss below come from a very detailed microsimulation model of health insurance decisions... analyzing the President's proposal for a health insurance tax credit in his FY 2003 budget."

"... the tax credit does have its intended effect of significantly increasing the purchase of nongroup insurance by the uninsured. But it also has an unintended effect of slightly eroding the group insurance market, so that the net reduction in the uninsured is fewer than 2 million..."

"One of the key debating points about those modeling tax credits for health insurance is the extent to which individuals will find low cost nongroup plans on which they can use their tax credit. This is an important issue because the costs of nongroup insurance plans are so high. For a 40 year old male in excellent health, the average cost of nongroup insurance is roughly $2000 per year. But these costs rise dramatically with age and poor health status. Indeed, in my data, for the typical uninsured family the cost of a nongroup policy is estimated to be roughly $10,000."

"The main disadvantage (of the President's tax credit proposal) is that this policy has a very modest impact on the number of uninsured in the U.S. My central estimates suggest that the number of uninsured will be reduced by fewer than 2 million, or 5% of the existing number of uninsured. This amount equals roughly the rise in the uninsured estimated to be caused by the recent rise in unemployment, according to a recent analysis by myself and the Kaiser Family Foundation."

"The other disadvantage of this approach is that it displaces, rather than supplementing, the group insurance market. The group insurance market remains the most effective way to deliver insurance benefits, through its use of large pools to minimize the variation in health risk to insurers. My estimates suggest that for every one person gaining insurance coverage, two persons will be leaving the group insurance market."

"... I am quite skeptical of claims that low cost policies can raise the effectiveness of this tax credit for two reasons. First, if such low cost policies exist today, why are there still 40 million uninsured Americans? The answer is that most Americans do not want catastrophic-type coverage; they apparently would rather be uninsured than buy low-premium, high out-of-pocket-cost policies. The enormous out-of-pocket costs that are typically associated with these low cost policies make them unattractive to the uninsured. Second, the very reason that such policies can be low cost is that they are only purchased by the very healthiest individuals for whom they are affordable; in other words, there is 'virtuous selection,' as opposed to 'adverse selection.' If a credit allows less healthy persons to purchase these policies, they will have to raise their prices to adjust for this higher cost risk pool. In other words low prices on these policies today do not guarantee low prices in the world of a health insurance tax credit; it seems likely that those low price policies will increase in price once more 'typical' persons are buying them."

"... raising the income limits (to increase eligibility for the tax credits) actually had pernicious effects on the insurance market on net: the reduction in the uninsured was unchanged, but there was a much larger net movement from group to nongroup insurance. As a result, the total cost of the policy rose by over one-third with no gain in insurance coverage. This finding highlights how important it is to keep tax policies tightly targeted."

(The full written testimony of Professor Gruber will be posted on the House Ways and Means webpage in about two months. These results are part of an ongoing project with the Kaiser Foundation to estimate the effects of tax credits and public program expansions designed to expand coverage for the uninsured; the full results from that project will be publicly released soon.)

Comment: This tightly targeted tax policy proposal would reduce the numbers of uninsured by 5%. What about the other 95%?

By supporting tax credits for the uninsured, the administration is conceding that government intervention is warranted. Then why not adopt policies targeting 100% of the uninsured? And a single risk pool would eliminate the problem of high cost plans in the non-group market.

How much longer are we going to play with the numbers? Let's adopt policies that, by their very design, will automatically solve our health care problems: global budgeting, single risk pool, universal coverage, and comprehensive benefits. We've repeatedly cranked the numbers for single payer reform, and they work. Let's do it.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

The Orange County Register
February 22, 2002
By Bernard J. Wolfson

Serious political and financial obstacles stand in the way of congressional action this year to fix any of the myriad problems afflicting the Medicare program, according to analysts and legislative aides who spoke Thursday at a health policy conference hosted by UC Irvine's graduate school of management.

Norman J. Ornstein, a political commentator and fellow at the American Enterprise Institute, raised the sobering possibility of yet another brake on Medicare action: a large-scale U.S. military attack against Iraq, which he said is in the planning stages and could happen this summer or early fall. At that point, all bets on domestic legislation would be off.

John E. McManus, Republican staff director on the House Ways and Means health subcommittee... said the interest of taxpayers must be respected in any Medicare legislation, and that costs can be held down more effectively if health-care consumers are required to shoulder a bigger share of the financial responsibility for their choices.

John McManus:

"Imagine if you had grocery insurance, and every time you went to the market your insurance paid 80 percent of it. You'd eat a whole lot differently -and so would your dog."

http://www.ocregister.com/search/, click "Browse the past 7 days," then "2-22-2002," then under "Business" click "Medicare fix doubtful this year, experts say."

Comment: This oft-repeated analogy of food insurance and health care coverage belittles the serious problems of hunger and health care access. The silliness of this argument is apparent when considering that none of those nations providing universal health care coverage also provide "grocery insurance," but most of them have better programs to assure that hunger is eliminated.

McManus' suggestion that Medicare beneficiaries should bear more costs (when they already bear half the costs of Medicare) will only result in greater financial barriers to health care access for the very large segment with only modest incomes. How can such an important public official support such cruel health policies and then glibly pass it off with a joke about dog food insurance? Ways and Means Chairman Bill Thomas should seriously consider replacing his staff director with someone who has at least a modicum of sensitivity for the needs of Medicare beneficiaries.

And please forgive me for being off topic by including the comment on the planning of the large scale U.S. military attack against Iraq. Personally, I'm in mourning for the soul of our nation. (I know that I will receive several requests to be removed from this list, but I had to speak up anyway.)

Don McCanne

Prof. Donald W. Light, on CalPERS and the Wennberg paper:

"This CalPERS announcement about its inability to hold down skyrocketing costs and the Wennberg paper on continued large disparities in funding reflect a systemic problem that the comments on Wennberg's article do not address. Every other industrialized nation has been able and is largely able to manage overall expenditures and to reduce the large disparities that most of them inherited because they have one or another kind of universal health coverage and management system. Some of them have competition, or contestability, within their overall frameworks; but a voluntary, market-based system is unable to address issues of inequality, overpricing, or overutilization."

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

California Employer Health Benefits Survey, 2001
February 2002

"...two-thirds (66%) of large employers (200 or more workers) and one-third (35%) of small businesses (fewer than 200 employees) say they are likely to increase what employees pay for health insurance in the next year."

http://www.kff.org/content/2002/3205/CAEHBIChartpack.pdf

Comment: California has been a leader in innovative models of health care coverage. Now there is discussion of the trend to shifting more health care costs to individuals. This isn't a trend; it's a tectonic shift.

California health insurance premiums increased 9.9% in 2001, more than double the inflation rate of 4.2%. Our current market oriented system of controlling health care costs has failed. Employers are finding the increases in costs to be intolerable. They are looking for relief.

Ironically, the one model of health care reform that would work is being excluded from almost all current discussions of reform. A single payer system would use global budgeting to freeze health care expenditures at the current level as a percentage of the GDP (or a comparable index that adjusts only for inflation). Businesses would no longer have to be concerned about increasing health care costs, not to mention being relieved of the administrative task of contracting for or managing health benefit programs.

As businesses look at their options, they should place on the table the single payer proposal. It will shine brightly sitting next to the other options.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

The Sacramento Bee
February 21, 2002
By Lisa Rapaport

The California Public Employees' Retirement System is exploring a radical overhaul of its health benefits program, admitting it can no longer use the market power of its 1.2 million members to hold down skyrocketing health care costs.

As HMO pullouts have forced members to enroll in CalPERS' two self-insured PPO plans, PERS Care and PERS Choice, those plans have seen their reserves dip to dangerously low levels. Members in those plans, meanwhile, have seen their rates increase much faster than their counterparts in the HMO plans.

Allen Feezor, CalPERS health benefits administrator:

"HMOs are aggressively managing their risk at the expense of PERS enrollees. If the situation is not addressed, it will jeopardize our statutory requirement to provide affordable health care coverage to all, regardless of age or location,"

Barbara Adachi, a regional managing director for Deloitte & Touche:

"CalPERS needs to act now to avoid further deterioration in its plans. There's an understanding that it will take time, but we already know that the market will not be able to solve the problems CalPERS faces."

http://www.sacbee.com/content/business/story/1653915p-1729331c.html

Comment: CalPERS is the nation's second largest provider of health benefit plans, surpassed only by the Federal Employees Health Benefits Program. And now there is general agreement that the market will not be able to solve the problems CalPERS faces. Why? The reasons are complex, but one important fact is that private health plans in the marketplace are mandated, based on "good" business practices, to avoid risk, shifting it elsewhere. Concentrating high-cost beneficiaries into CalPERS' self-insured plans demonstrates that size alone will not contain costs when the market is able to siphon off low-cost beneficiaries.

Haven't we had enough of these attempts to use the magic of the marketplace to control costs and provide comprehensive coverage for everyone. It is not as if we need to continue more real-life studies on the dynamics of the health care marketplace. The experiment has been completed with seemingly endless extensions that serve no other purpose than to prolong the life and profits of these failed marketplace health plans. It is time to end policies that prolong the viability of these parasitic middleman plans, and to enact policies that prolong the viability of patients!

A single, publicly administered, universal program of health insurance is precisely what we need. Let's go for it!

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Contacts:
Brady Case (617) 308-7035
Quentin Young, MD (312) 782-6006
Don McCanne, MD (949) 493-3714

1 in 8 Health Care Workers Lack Health Insurance

Harvard Study Finds Coverage Falling Fast for Health Personnel and Their Children, Particularly in Private Health Sector

A study published in today’s American Journal of Public Health finds that one out of every 8 health care workers lacks medical insurance, far more than a decade ago. The children of health personnel also suffered declining health coverage over the decade and now account for one in ten uninsured children in the US.

The study, by Harvard researchers Drs. David Himmelstein, Steffie Woolhandler, and Harvard medical student Brady Case, analyzed data from a national survey of approximately 150,000 US residents conducted annually by the Census Bureau.

1.36 million health care personnel were uninsured in 1998, up 83.4% from 1988. The proportion uninsured rose from 8.4% to 12.2%. Declining coverage rates in the growing private-sector health care workforce—and falling health employment in the public-sector, which provided health benefits to more of its workers—accounted for the increases. The authors argue that the growth of for-profit medicine during the 90s, and price pressures from managed care, led many health institutions to cut workers’ benefits. In effect, investors and executives gained at the expense of health personnel and their children. In 1998, 1.12 million uninsured children lived in households with a health care worker, accounting for 10.1% of all uninsured children in the U.S.

The study analyzed all employees in physicians’ offices, hospitals, nursing homes and other health services settings. Physicians, nurses, managers, aides, food service, cleaning, building service, and laundry workers, and clerical and administrative support workers were among the groups examined.

Insurance coverage fell for virtually every health occupation in every type of institution, though some groups fared worse than others. The number of uninsured health workers in the private sector doubled over the decade while in the public sector the figure declined. In 1998, 20.0% of personnel in nursing homes were uninsured—more than in other health settings. Among occupational groups aides experienced the highest rate of uninsurance—23.8%. Even among physicians, more than 1 in 20 (5.4%) were uninsured. Black and Hispanic personnel were at least twice as likely as white health personnel to lack insurance. Geographic variations were considerable; Texas had the worst record.

The falling coverage over the past decade is particularly worrisome because it occurred during a record economic boom. An even steeper increase in uninsurance is likely in the current recession.

“Over the past decade we’ve learned that for-profit hospitals and dialysis clinics have high death rates; that for-profit HMOs and nursing homes score lower on quality; and that health care fraud is epidemic. Now we learn that market medicine means not only poor care and high prices for patients, but mistreatment of health workers.” said Brady Case, a medical student at Harvard and lead author of the study. “It’s perverse. The health care system, squeezed by Wall Street, is consigning its own workers and their families to the ranks of the uninsured.”

Dr. Don McCanne, President of Physicians for a National Health Program, commented: “In denying care to caregivers, our health system defies the Golden Rule. And it’s not only wrong, but dangerous. When a nurse with a cough or a kitchen worker with hepatitis can’t afford care, patients are at risk. It’s time for the U.S. to adopt a single payer national health insurance program.”

# # #

Physicians for a National Health Program (PNHP) is an organization of over 9,000 physicians that support universal access to health care. PNHP was founded in 1987 and has chapters across the U.S. For local contact information or copies of “No Care for the Caregivers: Declining Health Insurance Coverage for Health Care Personnel and Their Children, 1988-1998” (Am J Public Health. March 2002) call the PNHP headquarters in Chicago at (312) 782-6006.

Contacts:
- Brady Case is a medical student at Harvard.
- Dr. Quentin Young is an internist and former President of the American Public Health Association. He also serves as the National Coordinator of Physicians for a National Health Program
- Dr. Don McCanne is the National President of PNHP and a retired family physician.
- Drs. David Himmelstein and Steffie Woolhandler are currently on vacation. They may be reached at their clinical offices at (617) 665-1032 starting February 28.

Posted by pnhp at 10:43 AM | Permalink | Comments (0)

Dr. Arnold S. Relman, Professor Emeritus of Medicine and Social Medicine at Harvard Medical School and Emeritus Editor-in-Chief of the New England Journal of Medicine, Presentation to the Standing Senate Committee on Social Affairs, Science and Technology

Mr. Chairman, Honorable Members of the Standing Senate Committee on Social Affairs, Science and Technology :

My name is Dr. Arnold S. Relman. I am Professor Emeritus of Medicine and of Social Medicine at the Harvard Medical School and former Editor-in-Chief of the New England Journal of Medicine. I have been asked by the Canadian Health Coalition to appear before you today to testify about the U. S. experience with private, for-profit health care.

I have been studying and writing about this subject for over two decades. In 1985 and 1986 I served on a committee established by the Institute of Medicine of the U. S. National Academy of Sciences to report on "For-Profit Enterprise in Health Care." During my editorship and afterwards, the New England Journal of Medicine published many articles in this field and, since I retired from that post, my own writings have continued to focus on this topic. I am now at work on a book that surveys the present unhappy condition of the U. S. health care system, with particular attention to the role of private enterprise.

My conclusion from all of this study is that most of the current problems of the U. S. system - and they are numerous - result from the growing encroachment of private for-profit ownership and competitive markets on a sector of our economy that properly belongs in the public domain. No health care system in the industrialized world is as heavily commercialized as ours, and none is as expensive, inefficient, and inequitable -- or as unpopular. Indeed, just about the only parts of U. S. society happy with our current market-driven health care system are the owners and investors in the for-profit industries now living off the system.

The U. S. may be a world leader in medical science and technology, and its major medical centers may provide some of the best and most sophisticated care available anywhere, but taken as a whole, our health care system is failing and will need major reform very soon. We have tried private for-profit markets, first in hospitals, in ambulatory care facilities and services, and in nursing homes, and then more recently, in the ownership of insurance plans - and the experiment has failed. Private health care businesses have certainly not achieved the benefits touted by their advocates. In fact, there is now much evidence that private businesses delivering health care for profit have greatly increased the total cost of health care and damaged - not helped - their public and private nonprofit competitors.

The U. S. experience enables students of health care policy to compare the performance of nonprofit and for-profit facilities as well as the performance of insurance systems, and the results are clear for all who want to examine the evidence. For-profit hospitals were much more expensive than their nonprofit counterparts when Medicare and private insurers simply reimbursed charges. That difference disappeared when the payers began to negotiate fixed prices, but there has never been any evidence that for-profit hospitals could provide similar services at lower prices than their nonprofit competitors. However, a recent study of Medicare per capita expenditures for all health services, including hospital care, found that they were much higher in regions served exclusively by for-profit hospitals than in regions where there were fewer or no for-profit hospitals.

There is no good evidence about the relative quality of hospital services in for-profit and nonprofit facilities, because such studies are difficult to do. Quality is easier to ensure in nursing homes and kidney dialysis centers. They are largely paid through fixed, negotiated prices by public insurance, and their products are more or less standardized. Studies that have looked at objective measures of quality of service show that public and private non-profit nursing and dialysis facilities provide significantly better and safer services to patients than their for-profit counterparts. This shows that when you fix the price and the services so that there is no wiggle room, non-profits clearly provide better care.

A little over a decade ago, for-profit investor-owned businesses took over the private insurance field, and now they cover more than half of our people - mainly through employers. More than a quarter of our population is covered by Medicare and Medicaid, which are largely financed by government. Comparisons of these private and public systems are instructive. The Medicare system has administrative costs of less than 3 percent, with all the remainder of expenditures going to physicians, hospitals and other providers. The private insurers, on the other hand, have corporate and administrative costs of 15 to 30 percent, and in addition outsource many other services they use to control costs by restricting the use of expensive resources. As a result, it can be estimated that only 50 to 60 percent of the premium dollar ends up with the providers, who themselves must pay additional administrative costs to deal with the regulations of the multiple insurers they must bill. And, while the private insurers at first held down premium prices by drastically cutting utilization, they have now run out of cost-cutting options and are meeting increasing resistance from providers and the public. Recently, premium prices of private for-profit insurers have again begun to increase at double-digit rates, more rapidly than the costs of Medicare and Medicaid.

A remarkable demonstration of the failure of the commercial, HMO insurance system was seen a few years ago when senior citizens covered by Medicare were encouraged to obtain their care from private, for-profit HMOs that would be paid by the government. It soon became obvious that the costs of care under the private system were much greater and that senior citizens were dissatisfied with the care they received. A wholesale exit of senior citizens from the private system ensued. They voted with their feet for the public system.

In short, the U. S. experience has shown that private markets and commercial competition have made things worse, not better, for our health care system. That could have been predicted, because health care is clearly a public concern and a personal right of all citizens. By its very nature, it is fundamentally different from most other good and services distributed in commercial markets. Markets simply are not designed to deal effectively with the delivery of medical care - which is a social function that needs to be addressed in the public sector.

We in the U. S. are belatedly learning this lesson and soon may be ready to try other options that will depend more on public action. Many of us south of the border have always believed that you Canadians had the right idea in deciding that the financing of health care is primarily a public responsibility. We still think you are right and that we ought to emulate you, rather than vice versa. I am surprised and disappointed in your Committee's Interim Report, which seems to favor policy options dependent on private market involvement in Canadian health care. Before making your final recommendations, I hope you will look more closely at the U. S. experience - which ought to convince most evidence-driven observers that markets can't solve public problems like health care - and in fact make them worse.

However, to make a publicly financed system work effectively, I believe both our countries need to begin reforming their medical care delivery systems. That is where we both ought to be looking for ways to optimize our use of resources and improve the quality of our health care.

I believe that splintering the delivery system into many different, highly specialized facilities, as has been proposed in both our countries, is not in general a sound option for improving quality and effectiveness. A much better approach would be to re-organize how physicians work together. Both our countries now depend largely on independent solo medical practitioners to provide ambulatory and hospital services on a fee-for-service basis. We should both begin to encourage physicians and other health care professionals to organize themselves into self-governing, multi-specialty and multi-disciplinary teams to deliver comprehensive care at prepaid, capitated rates. Physicians provide the best care when they work in teams, not as competitors. Furthermore, to discourage over service, they should be paid primarily for their time, and not on a piecework basis. That would reduce both fraud and the resources wasted on the processing of claims.

Finally, I want to say just a word about "consumer choice," which is now being touted in the U. S., and I gather in Canada, too, by believers in the magic of the market as a mechanism for controlling costs and improving the quality of services. While there is much to be said for making more information available to people about their health care, it is a fundamental misconception to imagine that sick patients can or should behave like ordinary consumers in commercial transactions, selecting the services and prices they want. Health care is totally different from most goods and services, and that's why we have medical insurance and why sick people need the professional and altruistic services of physicians and other providers.

I suspect most Canadians understand why health care is special and why it needs to be insured by a public system like the one you now have. I would be surprised if they want the fundamental fairness of their Medicare system to be changed by the introduction of market forces.

Thank you for your attention.

Posted by pnhp at 03:31 PM | Permalink | Comments (0)

The Washington Post
February 19, 2002
By Abigail Trafford

"With pomp and circumstance and the glare of TV lights, representatives from 12 leading health, business and labor organizations signed a proclamation to 'come together from diverse perspectives to seek solutions to one of America's greatest problems.'"

"But the marching spirit of the summit conference started to sputter as soon as the health care moguls were asked about solutions. Out came the old buzzwords of stall, stall and stall: 'Incremental,' said one chieftain. There would be no one solution but a number of possible steps to chip away at the problem. 'Public, private, incremental, long haul,' agreed another. 'Progress will be slow,' said the consumer representative. 'We have to keep the best we have and allocate resources,' added another leader. 'Incremental,' echoed another."

"To find solutions, each leader at the summit has to be willing to lose a little for the country to gain a lot. 'Incremental' is not a word that helps Potter, Hegdal or Henderson (examples of the plague of 'uninsurance'). They're not interested in 'slow progress.' They need coverage now. The uninsured have been waiting for decades for some relief."

"So let's give the chieftains 90 days to come up with a unified plan. After that, to return to the civil rights mode, it may be time for a march on Washington."

http://www.washingtonpost.com/wp-dyn/articles/A18970-2002Feb15.html

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Contacts:
Linda Peeno MD (502) 895-9761
Joanne Landy (212) 666-4001
Don McCanne MD (949) 493-3714

Showtime contacts:
Michele Morris (310) 234-5222
Joan Ziff (212) 808-1590

Humana Medical Reviewer Admits to Denying Heart Transplant
Second “John Q” Movie – Starring Laura Dern – Coming out in May

Louisville – Former Humana Medical Reviewer Dr. Linda Peeno was so disturbed by what she experienced working for the giant HMO – including denying a young patient’s heart transplant – that she went into medical ethics and is now a vocal advocate for a national health insurance program.

A movie based on Dr. Peeno’s experiences, called “Damaged Care” and including a scene showing her denying a patient’s heart transplant, is coming out on Showtime in May. Laura Dern (“Jurassic Park”) plays Dr. Peeno. Dern also co-produced the film. Dr. Peeno testified before Congress in May of 1996 about her heart transplant case and has been outspoken about the right to health care ever since.

“As a physician working for Humana, I denied a young man a heart transplant that would have saved his life, and thus caused his death,” testified Dr. Peeno. “No person or group has held me accountable for this, because, in fact, what I did was I saved a company a half a million dollars.”

“Humana’s only concern was costs,” says Dr. Peeno. “The young man fit all the criteria, a donor had been found, his doctor was ready to do the operation. Meanwhile, behind the scenes Humana employees scrambled to find a loophole in the patient’s contract. When they did, I was the one who had to tell the surgeon that the operation would not be covered.”

“The doctor asked me if I knew that the patient would likely die of his condition without the surgery, and I said I knew.” says Dr. Peeno. “When I hung up the phone my colleagues at Humana were thrilled, even joyful. I was sickened.”

The movie “Damaged Care” stars, in addition to Laura Dern, James LeGros, Adam Arkin, and Michelle Clunie, and features Regina King and Dianne Ladd. It is being distributed by Paramount Network Television. It was directed by Harry Winer.

Dr. Peeno recalls that shortly after denying the patient their heart transplant, a gigantic piece of sculpture was purchased for Humana’s headquarters – costing about the same amount as the heart transplant she had denied.

“When HMO’s came on the scene, we were told that they would eliminate only the “inappropriate care” and they would reduce costs so everyone could have insurance. Exactly the opposite has happened. They deny and delay needed care with sophisticated techniques, consume enormous resources for overhead costs and profits, and health care costs are rising dramatically.”

“Our health care funding system is sick,” says Dr. Don McCanne, a retired family physician and President of Physicians for a National Health Program. “If people only understood that we are already paying enough to provide comprehensive coverage for everyone – including heart transplants – if we only cut out the insurance middlemen and adopted a national health insurance program.”

The New York Chapter of PNHP leafleted outside a movie theater at the premier of John Q in New York City. “Everyone we spoke to agreed that we need health care reform,” says Joanne Landy, Executive Director of NYC-PNHP. “The public is overwhelmingly in favor of getting rid of the HMO’s and adopting a national health program.”

####

Physicians for a National Health Program (PNHP) is an organization of over 10,000 physicians that supports a single payer national health insurance program. PNHP is based in Chicago with chapters across the US. For local contact information, call (312) 782-6006. www.pnhp.org

Dr. Linda Peeno is a family physician, medical ethicist and medical-legal consultant in Kentucky. She was the recipient of the 2001 “Dr. Quentin Young Health Activist Award”.

Posted by pnhp at 10:46 AM | Permalink | Comments (0)

United States House of Representatives
Committee on Ways and Means
February 13, 2002

(Dr. Stuart Butler, Vice President of the Heritage Foundation, and others provided extensive testimony on the use of tax credits to assist with the purchase of health insurance in the private market.)

The testimony continues:

Chairman Bill Thomas (R-CA): Mr. Stark? We only have about four minutes.

Rep. Pete Stark (D-CA): ... I'm gonna guess that we could provide Medicare for the under 65 population for probably 3,000 bucks a year. It was 4,000 for the 55 to 65 for the buy-in, so I'm extrapolating. Kids are only about 1,000 bucks, so you can fuss with me about the 3,000. But, I'm pretty close. If you add a maximum co-pay of 1,000 bucks, one day in the--one exposure to the hospital and 100 bucks for the doctor, you're talking about, at most, $4,000 for a plan that--I handed out this list of benefits that I got off the e-group--that's probably just as good as that, and if you--most of those had a $3,000 premium and a $1,000 co-pay. So, you could have Medicare with completely open enrollment and community rating, and why would anyone, therefore, object if using this tax credit, we allow people to purchase Medicare as an alternative? That's all we'd need to keep the insurance companies honest. If they want to compete, let 'em compete. And we already have it for the seniors where, obviously, the private insurance didn't want to compete. And so, I'd be perfectly willing to say, "Okay, let's do it," but just let Medicare offer a plan at budget net--cost as we do now with the subsidy for Part B, no higher, and provide it that way? Who'd object to that?

Dr. Stuart Butler (V.P. - Heritage Foundation): Well, I think you'd immediately see, of course, the adverse selection against Medicare, which is one of the big concerns with that. The people who would quickly and immediately take that option would be the people with the highest cost--.

Rep. Stark: Yeah, but adverse concern is the guy who doesn't get any insurance through the private market.

Dr. Butler: Well, I understand that. But, I'm just trying to point out that the cost of providing that coverage is--.

Rep. Stark: It's interesting how the (inaudible) is always worried about the poor people and the sick people first, as they're jamming it to us rich, healthy people? I like that, Stuart. You're true to form, always worrying about the rich people, never give a hoot for the poor.

Dr. Butler: Well, I--.

Rep. Stark: --At least you're consistent.

Dr. Butler: I think my record's very clear on that, Congressman.

Rep. Stark: Yes, your record is very clear. You don't give a rat's behind for the poor and the indigent. All you worry about is rich people getting their tax breaks.

Dr. Butler: Well, Congressman, I've actually--.

Rep. Stark: --Your career is outstanding in that regard.

Dr. Butler: If you look at the proposal--actually--.

Rep. Stark: --God bless you. Keep it up.

http://www.kaisernetwork.org/health_cast/uploaded_files/hwa021302.pdf

Comment: Mr. Stark, in his mastery of the eloquence of the lay language, has left no doubt as to the fundamental issue that lies behind the debate on health care reform. Maybe we should proceed with this debate. Let's decide once and for all whether we, as a nation, give a rat's behind. If we don't, let's not waste more time and effort on health care reform. But, if we do, let's quit wasting our time trying to incrementally create a system that can be accepted by those that don't give a rat's behind. There is no such system. The enemies of reform will always try to silence the hoot that we want to give to the poor. If you doubt this, then ask yourself why a few decades of incremental reform have resulted in more uninsured, higher costs, and greater impairment of access to health care. The collectors of rat's behinds have silenced almost every hoot of each reform measure.

Single payer reform would provide comprehensive care for everyone and effectively address the cost issue. Let's leave the enemies of reform in their vaults, counting their rat's behinds, while we move on with real reform. Let's fix the damn thing now. Let's enact a single payer system.

Joshua Freeman, M.D., Professor and Chair, Department of Family Medicine, University of Kansas Medical Center, responds to Kip Sullivan on the Wennberg proposal:

I agree pretty much with Sullivan. Two comments:

1. The biggest problem with Wennberg, Ellwood and others is that the ownership of the care providers by private, corporate, for profit entities precludes not only privacy, but true cost-effectiveness, as it inescapably alters the motivation for everything that such providers do. This, not prospective payment, large groups, etc., is the problem with HMOs-in-their-current-form.

2. Sullivan is correct of course about prospective studies. My concern is that new IRB regulations, with the intention of protecting privacy of patients, will preclude a lot of people-based (as opposed to lab-based) research. Thus, it will not hurt those currently most NIH funded whose work is least likely and with the longest time lag to benefit people (but has the highest status, since it isn't susceptible to as much variation as studies involving actual people, with their undisciplined habits of variation!) but will be a real threat to clinical and in particular social science research on things that may be of greater immediate benefit (this has nothing to do with Wennberg or really Sullivan, but is a thought I had on reading Sullivan).

Uwe Reinhardt, Ph.D., responds to the Pete Stark - Stuart Butler exchange during the House Ways and Means hearing:

I do understand Pete's frustration and anger, and I share the sentiment. Pete has been a constant champion of the poor over the years and he must be deeply saddened at the 1990s. But I do not think that he was being fair to Stuart Butler.

To be sure, Stuart has a strong bias in favor of private market solutions--he, like Mark Pauly, has a deep-seated belief that government solutions invariably breed inefficiency and corruption, just as others have a deep-seated belief that private, for -profit enterprise is inherently anti-social. On the other hand, I know that both Mark and Stuart do care deeply about the welfare of low-income people, would very much like to see them all insured, and have worked hard over the years to work out politically feasible proposals to achieve that goal--proposals that have varied with the political temper of the times. They are not callous people. There really is such a thing as a compassionate conservative, and these two fall into that class (as President Bush does not--for he lacks the first of the "c's").

In fact, none other than former New Republic editor Michael Kinsley (recently retired from Slate) called Stuart Butler's original proposal (JAMA, around 1992) the most liberal proposal at the time, measured by the ultimate incidence of the fiscal burden and the degree of protection it offered. It may be recalled that the Urban Institute judged the financing of the Clinton Plan regressive in its incidence.

It is worth re-reading that old Heritage Foundation proposal to appreciate just how far we have sunk in terms of social ethics. Today it would be dead on arrival. Even Al Gore would have decried Stuart's proposal as "reckless spending."

Uwe

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Hundreds of thousands of Americans watched this weekend as a desperate father held a hospital emergency room at gunpoint and demanded a heart transplant for his dying son. Fortunately for everyone, it all happened in a movie, 'John Q,' which opened Friday

Los Angeles Times
February 18, 2002
'John Q.'s' Public Warning By Benedict Carey

Hillel Laks, M.D., Professor and Chief, Division of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles:

"It's very important for people to know what their insurance pays for, and to know they can do something about it. John Q. could have gone to the company and said, 'I don't like this policy. I want to spend $100 more and get better insurance.' If he's willing to go shoot people to save his son, why can't he pay a little extra a month to make sure he's covered?"

http://www.latimes.com/features/health/la-000012439feb18.story?coll=la%2Dheadlines%2Dhealth

Comment: Professor Laks is a noted and respected expert on heart transplants. However, before he ventures further into expressing public opinions on health policy, I would emphatically recommend that he become more versed in the basic fundamentals of this discipline. He might begin by reading "Understanding Health Policy" by Thomas Bodenheimer and Kevin Grumbach.

Importunely, Dr. Laks' response represents the prevailing view of the leadership of the medical associations, of many business leaders, and the conservatives and many moderates who now control the political agenda. Their rhetoric is that control of health care should be shifted to the consumer, and this is done by defining the contribution of either the employer or the government and then allowing the beneficiary-patient to have "choice" of the type of coverage by contributing the balance of the premium. That "choice" for those with very limited income and assets, such as John Q and another 100,000,000 or so in the United States, either requires an often unaffordable premium, or requires that the individual select options with unaffordable out-of-pocket expenses. For the benefit of Dr. Laks and others that don't seem to quite get it, in health policy terms, this is called "defined contribution" and "shifting risk to the beneficiary."

In fact, everyone who is going to take a stand on issues of health policy should read "Understanding Health Policy." If individuals are going to support cruel and inhumane health policies, they should understand exactly what they are doing. In this age, they should not be allowed the intellectual laziness and the "Let them eat cake" insensitivity of proclaiming, "Let them have choice," and then walking away from the problem.

Understanding Health Policy: http://shop.mcgraw-hill.com/cgi-bin/pbg/0071378154.html?id=aaHGHsD3

Kip Sullivan, responding to the Wennberg et al proposal for Medicare reform:

I agree with your statement that Wennberg et al. have presented a compelling argument that Americans are exposed too often to overuse and underuse of medical services. And I agree as well that Wennberg is wrong to promote HMOs as the mechanism best suited to reduce overuse and underuse. However, I want to call attention to a proposal Wennberg makes that you didn't discuss which I believe is dangerous and doomed to fail.

Wennberg, like all managed-care advocates, believes quality (overuse, underuse, and misuse) can only be improved if the structure of the health-care system is changed, and if patient privacy is destroyed (or, at best, placed at grave risk). Wennberg shares two beliefs with Paul Ellwood and other managed-care advocates: (1) quality cannot be improved unless doctors are herded into large entities -- preferably HMOs -- that have enough power over doctors to force, cajole, and/or educate them into changing their practice style, and (2) patient medical files are dumped into large information depots, preferably national depots, and these depots are used by researchers to determine "best practice." Both beliefs, casually and frequently expressed by the managed-care crowd, have never been elaborated, and certainly never proven. I think both beliefs are nonsense. A thorough refutation of this nonsense would take up more time than I have today. I comment on just two issues.

The notion that doctors can improve their understanding of the massive medical-science literature only if they leave solo practices and join large networks of docs or HMOs makes several bogus assumptions, the most important of which is that the bureaucrats who head up the network or HMO do have plenty of time to keep up with the medical literature, and, given their superior knowledge and their managed-care tools (utilization review, financial incentives, etc.), are capable of forcing or inducing the army of doctors under their command to weed out the "bad practices" and nourish the "best practices." Just saying this seems to me proof enough of the silliness of this proposal, but if there are people on this list who would like to question this statement, please do. This is a complex issue and I'd be happy to expound.

The second premise I want to quarrel with is Wennberg's assumption that medical research has been shackled, lo these many centuries, by the absence of national or regional information depots containing all information on all patients. (To my knowledge, Paul Ellwood was the first person to make a big splash promoting this nonsense. He did so in a 1988 article for the New England J Med.) The problems with this proposal are numerous and mind-boggling.

The most serious problem with the notion that advances in medical science depend on researchers trolling through millions of patient files is that it pretends, without saying so, that the historic methods of advancing medical science were never any good, or were terribly inefficient. The gold standard in scientific research is, of course, the prospective, controlled trial. Trolling through patient files after patients have received medical care is, by definition, a retrospective methodology. You can do your best to control for variables that could affect outcomes, but as a rule you'll never control for all relevant variables with a retrospective methodology as well as you will with a prospective methodology. I'm not saying retrospective research is useless. I'm merely calling attention to an obvious fact -- medical science, excuse me, "identification of best practices" will advance faster if we rely primarily on prospective methods, and that increasing the number of retrospective studies based on huge information depots (as opposed to the old-fashioned technique of asking a sample of patients for consent and then reviewing their files) will accomplish relatively little. To put it another way, if we never create gigantic information depots, medical science will continue to advance by the same route it always has -- by basic research, by randomized (prospectively designed) clinical trials, by retrospective research using relatively small patients samples, by clinical experience, and by serendipity.

Note the advantage to patients in the old-fashioned methods of advancing medical science -- our records are used with our consent. Under the Wennberg proposal, all records (not just that portion relevant to the study) on all patients (not just a sample of patients) are routinely dumped into the depot and kept there till the end of time (which is a much longer violation of patient privacy than the period of time required by the typical old-fashioned prospective or retrospective study).

And I haven't even discussed the cost of the Wennberg-Ellwood boondoggle.

I think single-payer advocates should state clearly that one of the advantages of a single-payer system is that patient privacy will not be destroyed. To make that promise, we have to reject the HMO advocates' claim that quality of care can only be maintained or improved if patient files are routinely inspected by researchers. We should instead promote much more old-fashioned research, and more education of doctors and patients about the results of that research.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

The Globe and Mail (Toronto)
February 12, 2002
By Virginia Galt

"Labour costs could shoot up, jeopardizing one of Canada's key competitive advantages, if universal health care is eroded and unions go after employers for private coverage, industrial relations specialists say."

The Conference Board of Canada, in a recent briefing paper on corporate health care costs in Canada and the United States:

"Any policy debate on the future of the health care system of Canada should recognize not only medicare's symbolic value to individual Canadians, but also its economic contribution to the competitiveness of Canadian businesses vis-à-vis the United States."

http://www.globeandmail.com, and under Search" and "This site" enter "Medicare cut" and click "Go"

Beth Capell, Ph.D., responding to the Urban Institute report on the safety net:

The only "safety-net system" proposals that would give the uninsured the same access to care as the insured require that the safety net is as well funded as insurance coverage and as readily accessible. None of these so-called safety net proposals mentioned by Holahan and Spillman, much less the Bush proposal, approach that level of funding and accessibility, to the best of my knowledge. In California, we would need to spend an additional $8-$10 billion a year to fund care for the uninsured comparable to the cost of coverage. Short of that, the safety net will always be inadequate. Even with that, given the well-established correlation of poverty and ill health, funding for the uninsured may not be sufficient--but it would be much closer.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Urban Institute
By John Holahan and Brenda Spillman

"The weakness of the safety net does not appear to worsen the uninsureds' access to care. Conversely, a relatively strong safety net does not appear to improve their position relative to the insured. No matter how the uninsured are supported-whether by third-party payers, the presence of community health centers, a high level of disproportionate share payments, or local government subsidies-we find no evidence that these efforts have the ability to eliminate, or even narrow, barriers to access to the extent that insurance can."

http://newfederalism.urban.org/html/series_b/b42/b42.html

Comment: The Bush administration is touting proposals for expansion of health insurance coverage, such as very modest tax credits, that will have little impact on decreasing the numbers of uninsured. Instead, their emphasis has been shifted to supporting the health care safety-net through programs such as increased funding for community clinics. (Even the seriousness of this commitment can be questioned in light of the 33% reduction in funding resulting from the elimination of the Medicaid upper payment limit for safety-net institutions.)

This study challenges the assumption that strengthening the safety-net system will provide a substitute for the lack of insurance coverage. The relative strength of the safety-net does not alter access to care. In sharp contrast, insurance coverage, or the lack thereof, dramatically impacts access to health care.

Although this study demonstrated that weaknesses in safety-net systems can be compensated for by the remainder of the health care community, it is important to note that there may be an as yet unidentified threshold at which safety-net systems can collapse resulting in further impairment of access for the uninsured. So it is important to maintain the integrity of the safety-net system until we finally resolve the deficiencies in our methods of funding health care.

But the bottom line is that we must make every effort to provide comprehensive health care insurance for everyone. We now know that the only way that we can do this equitably, and still afford to pay for it, is through a single payer system. Let's start the planning process today!

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Health Affairs
Web Exclusive
February 13, 2002

"A reform proposal that addresses some underlying causes of Medicare funding woes: geographic variation and lack of incentive for efficient medical practices."

by John E. Wennberg, Elliott S. Fisher, and Jonathan S. Skinner

ABSTRACT:

Medicare spending varies more than twofold among regions, and the variations persist even after differences in health are corrected for. Higher levels of Medicare spending are due largely to increased use of "supply-sensitive" services - physician visits, specialist consultations, and hospitalizations, particularly for those with chronic illnesses or in their last six months of life. Also, higher spending does not result in more effective care, elevated rates of elective surgery, or better health outcomes. To improve the quality and efficiency of care, we propose a new approach to Medicare reform based on the principles of shared decision making and the promotion of centers of medical excellence. We suggest that our proposal be tested in a major demonstration project.

http://www.healthaffairs.org/WebExclusives/Wennberg_Web_Excl_021302.htm

Comment: John Wennberg and his colleagues have previously provided more than ample data to confirm that for even those who have access to care and can afford it, Americans are receiving poor value for their health care dollar. Many services are of no benefit and may be detrimental, and other beneficial services are not being delivered. Mediocrity in care is not limited to low-income, uninsured and under-insured individuals, but it is a characteristic of our entire health care system, with some exceptions.

In this report, Professor Wennberg and colleagues demonstrate that doubling spending in Medicare does not result in more effective care nor better health outcomes. They do demonstrate that this increase in spending merely results in increased use of hospitals, intensive care units, and, especially, medical specialist services, but with no improvement in the index of effective care. Clearly, efforts must be made to reform not just Medicare, but our entire health care system.

Professor Wennberg's group proposes a fresh approach to Medicare reform including promotion of effective care and patient safety, reducing unwarranted variation in preference-sensitive care, reducing overuse of supply-sensitive care, refining monitoring systems, and rewarding more efficient resource use. They mention how this can be studied and implemented quite readily within the Medicare program. In fact, after reading their proposal and giving it some thought, it is clear that a single payer system would form the ideal infrastructure for implementation of these measures that would improve quality and efficiency.

They briefly mention the inequities that might result from implementation of a budget cap, but even those inequities would be more readily addressed through a single payer model than they would through a fragmented system of multiple payers. They also suggest that the Breaux-Thomas model might have a place in competitive strategies, although cooperative strategies should also be considered. However, integrated health systems are the entities that would be competing based on best-practice models, and the business-model health plans characteristic of the B-T proposal would add administrative waste and change the focus from best practices to dollar-flow management. Thus there is no reason to blindly follow the path of incrementalism merely because the authors state that it is more likely in the near future.

This article must be read by everyone who wishes to help improve our health care system. Professor Wennberg, et al, have indicated the direction for reform. It is our task to demonstrate that the single payer model provides the ideal infrastructure for implementing their proposals.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Jonathon Ross, MD, MPH, past president of Physicians for a National Health Program:

Have you seen the ads or the trailer for the movie John Q? Denzel Washington plays a man whose son needs a transplant and ends up going postal when he is told that it is not a covered benefit. I was at the movies when the trailer played.

The trailer finishes with DW holding a hostage and a negotiator saying to him, "How is this going to end, John?"

I couldn't help saying out loud at the end of these words at the end of the trailer, "National Health Insurance!"

And the audience of about 100 broke into cheers.

Comment: "John Q" opens at theaters today. It has already provoked considerable discussion. Today's reviews by movie critics are a mix. Some criticize it for using stereotyped characters with predictable behavior. Some criticize dramatizing the use of a violent response (using a gun to take hostages) for a very serious social issue (our failed system of paying for health care). But others clearly acknowledge that the message is very real, that the crisis in insurance coverage today literally threatens lives (though normally much more subtly than in this portrayal).

Discussion of this film has moved from the entertainment section to the news section of the media. And it is the message of the insurance crisis that is being discussed. The anticipated impact is great enough that the American Association of Health Plans is conducting an advertising campaign to deflect the blame to others.

While we need to be sensitive to the fact that violence is used to represent the intensity of the desperation of this fictional father, nevertheless, the nation will be discussing this film and the insurance crisis it portrays. We need to be there to show them that we do have a solution: comprehensive care for everyone with no increase in costs, through single payer health care reform.

For those that have the QuickTime 5 program, the John Q trailer can be viewed at: http://www.apple.com/trailers/newline/john_q.html

Although some may object to specifying single payer reform as the answer, remember that the preliminary results of the California Health Care Options Project demonstrate that only single payer or health service models will provide truly comprehensive care for absolutely everyone, and that they actually reduce health care costs, whereas the incremental models studied fail the tests of universality and comprehensiveness and actually increase health care costs. It is time to refute and chastise those that say that we should stifle the talk of single payer because of political expediency. Single payer is the moral imperative in health care reform. We need to agree on that and then move on with reform.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

The New York Times
February 14, 2002
By Milt Freudenheim

"Elderly and disabled members of Medicare H.M.O.'s used nearly 50 percent more of their own money on average for medical care in 2001 than they did three years ago, health care researchers said yesterday."

"Out-of-pocket costs rose 62 percent to $3,578 in 2001 for people in poor health as their share of spending rose for prescription drugs, premiums and other services not fully covered by Medicare."

Marilyn Moon, a Medicare policy expert at the Urban Institute:

"Many people joined H.M.O.'s to try to reduce out-of-pocket expenses. The bargain was, 'we will give up some of our control over medical services in order to have some of our costs reduced.'"

John Rother, legislative and policy director of AARP:

"No one is looking at H.M.O.'s any longer as a way of saving money for Medicare. The reality is, fixing these problems is going to cost some money."

http://www.nytimes.com/2002/02/14/health/14CARE.html

Comment: The Medicare+Choice options were able to offer pharmaceutical coverage and lower out-of-pocket expenses primarily because of their success at enrolling relatively healthy patients. For several reasons, they no longer have the margins that will allow this largess.

The administration and some members of Congress now want to increase funding for these private sector plans which would allow them to continue to offer richer benefit packages. But these plans are not available to everyone, and they vary in their generosity. Why should those that remain in the traditional Medicare program be denied benefits that the private plans provide? They shouldn't. They should have the same pharmaceutical coverage and reduced out-of-pocket expenses. We know that the plans would not be able to provide identical services at the same price, and they would likely go away.

If the administration really believes that the enrollees of private plans are entitled to these extra benefits, then they must believe that those in the more efficient traditional program should be entitled as well. We do still believe that our taxes should be used equitably. Don't we?

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

The Washington Post
February 12, 2002

By Thomas J. Donohue, President and CEO of the U.S. Chamber of Commerce, and John J. Sweeney, President of the AFL-CIO

"When representatives of business and labor meet, it's usually across the table. Today there is an issue in America that compels us to sit side by side."

"It is the quiet crisis of the uninsured. For all our miracle cures that are saving lives every day, we have failed to solve our biggest health problem -the fact that so many Americans lack access to even the most basic care because they lack health coverage. It has gotten worse despite good economic conditions, and it certainly won't improve during a downturn. Today, we are urging our fellow Americans and elected leaders in Washington to join with us and begin the hard work needed to solve this problem."

"We have different perspectives on the problem, as do our partners in this effort - employers and workers, insurers and consumers, doctors, hospitals and nurses. Though we will undoubtedly disagree on specific solutions, our unified goal is to make the problem of the uninsured our nation's top health priority and to help America solve it."

http://www.washingtonpost.com/wp-dyn/articles/A60625-2002Feb11.html

Comment: Another step backwards. "We will undoubtedly disagree on specific solutions," is a concession that no interested party is willing to abandon its own agenda. And, even though the preliminary findings of the California Health Care Options Project reveal, once again, that single payer models can assure comprehensive health care for everyone while reducing overall health care costs, the parties involved in this latest process have already rejected single payer reform before the discussions begin. They will continue to look at various solutions that the California study indicates will only increase health care costs while perpetuating flawed health policies.

Twelve organizations plus the Robert Wood Johnson Foundation have set up a website for this new effort to publicize the plight of the uninsured and to begin to seek solutions. The website: http://www.coveringtheuninsured.org/

The glossary at this website is revealing in that it includes terms such as medical savings accounts, catastrophic health insurance, purchasing pools, tax credits, refundable tax credits, group insurance, flexible spending accounts, cafeteria plan, FEHBP, HMO, PPO, managed care, and other concepts that the various factions continue to debate. But conspicuously absent from the glossary is which term? Single payer! Not only should it be in the glossary, it should be on the negotiating tables!

http://coveringtheuninsured.org/glossary/

The compromise recommendation that will be reached is quite predictable when considering the organizations that are participating and the positions already taken by each of these entities. The organizations include the U.S. Chamber of Commerce, the AFL-CIO, The Business Roundtable, SEIU, the American Medical Association, the American Nurses Association, the Health Insurance Association of America, Families USA, American Hospital Association, Federation of American Hospitals, Catholic Health Association of the United States, AARP, with the support of The Robert Wood Johnson Foundation. There will be general agreement that public programs should be expanded in order to cover the low-income sector. The affluent will be granted medical savings accounts and other options. And the great compromise will be that tax credits will be accepted as the means of providing access to coverage for the majority. Without elaborating on the serious flaws inherent in this approach, there is no question that the result will be that health care costs will continue to escalate, and greater financial barriers will be erected thereby further impairing access to care.

Representatives of each organization spoke at the press conference announcing this effort. They all agreed that they were committed to compromise with most of them specifying that reform would be "incremental." Most alarming was U.S. Chamber of Commerce's Donahue stating:

"The other thing we should know is that there are a lot of private conversations going amongst the people here. I mean, we didn't just show up here today to, you know, make a statement. We've been having a lot of conversation and I'm encouraged by it because it hasn't got the vitriolic kind of who shot Jack, you know. It's really-if this is the kind of problem-then how could we fix it and what ways might work."

"If we move vigorously towards a single payer system which, by the way, doesn't work anywhere in the world, we're gonna find a great migration away from the people that are providing the coverage, and we can't afford that."

http://www.kaisernetwork.org/health_cast/hcast_index.cfm

The fix is on. They already shot Jack! How could a process that begins with an agreement to keep the strongest advocates of health care justice, the single payer advocates, out of the negotiating rooms ever result in a just health care system? Tragically, special interests already have killed another attempt at rational reform before it even got off the ground.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

February 2002
Managed Care Plan Out-of-Pocket Expenses in 2002

In summary, review of the out-of-pocket costs for California consumers enrolled in Medicare+Choice plans for 2002 shows that:

* Premiums are not necessarily an indicator of total out-of-pocket expenses.

* Expenditures are difficult to project at the time of plan selection due to the detail and plan complexity of the terms related to co-payments, deductibles, and coverage limits.

* Total out-of-pocket costs may exceed thousand of dollars over the course of the year.

http://admin.chcf.org/documents/medicare/MedicareTrends2.pdf

Comment: California, the great testing-ground for innovative insurance products, has had more than ample experience with the Medicare+Choice options. The initial perception that these options were successful business models was due to the fact that initial enrollees were a healthy subset of the Medicare population. That subset is now older, less healthy, and more expensive. The magic trick proved to be another illusion. The reality is that these plans cannot provide more services, at a lower cost, while supporting expensive private bureaucracies.

To no one's surprise, the plans are now in Washington, with hat in hand, pleading for more funds in the face of a Spartan budget. And Tom Scully, Bill Thomas and Nancy Johnson are attempting to change the rules to allow diversion of more funds to this industry, while penuriously posturing by failing to correct the slash in rates that will inflict serious damage to the traditional Medicare program.. They have it wrong. It is not the industry that needs support, but rather the patients. Most urgent is the need for bona fide prescription coverage. Let's use our Medicare tax dollars for Medicare patients, not egregiously wasteful private bureaucrats.

Emanuel Gale, Emeritus Professor of Social Work and Gerontology, California State University, Sacramento, responds to the California Health Care Options Project:

The HCOP has been an interesting social policy exercise, in moving towards universal coverage.

My personal recommendations for HCOP are that:

1. In the current political climate, a national approach to universal coverage is unrealistic. States must therefore assume a leadership role.

2. The State of California should adopt a Constitutional Amendment that, "Health Care is a fundamental human right for all residents."

3. There needs to be a priority for developing a "wellness" vs. the current "sickness" model.

4. The authors of the Incremental Reforms collaborate on a single proposal, to maximize the number of uninsured persons to be covered, within a three year time frame. This would be viewed as an interim first step, leading towards a single payer proposal.

5. The authors of the Single Payer proposals and the Employer Contribution proposals, collaborate on a single payer proposal to assure universal coverage, beginning at the end of the three year incremental period, and transitioning over the next five year period.

Without campaign finance reform, there has to be a prohibition of campaign contributions to an elected Health Commissioner, by the vested interests in health care. (e.g. Chuck Quackenbush, former Insurance Commissioner)

Achieving these objectives requires major investments in political and community organizing at the grass roots level, and the political will to foster radical changes in the current "sick" health care system.

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

http://www.healthcareoptions.ca.gov/

"An estimated 22 percent of Californians do not have health care coverage. The Health Care Options Project (HCOP), led by the California Health and Human Services Agency (CHHS), is designed to examine various reform options for extending health care coverage in California. The project is consistent with the objectives of Senate Bill 480 signed by the Governor in 1999.

"Nine reform option papers have been developed for HCOP. They include public program expansions, individual and employer tax credits, employer and individual mandates, single payer models, and combination approaches. Two-page summaries and drafts of these proposals are available in the document library of this website. The reform options will be analyzed and compared using a micro-simulation model developed by The Lewin Group under a contract with HCOP. This model is also available in the document library for your review and comment.

"We encourage readers to review these materials and send comments to HCOP at SB480@library.ca.gov. For your convenience, we have added a one-page comment sheet to the document library that you can use to provide feedback on the paper(s) of your choice. These sheets can be returned by e-mail or mailed to Peg Gerould, California Research Bureau, 900 N Street, Suite 300, P.O. Box 942837, Sacramento, CA 94237-0001. Comments will be forwarded to the appropriate authors for their consideration as they continue to develop their reform options."

The link for the HCOP website: http://www.healthcareoptions.ca.gov/

The brief summaries of each proposal: http://www.healthcareoptions.ca.gov/Summaries_112601.pdf

The comment sheet for providing feedback: http://www.healthcareoptions.ca.gov/webcomments.pdf

The index to the entire HCOP document library, including preliminary full drafts of each proposal: http://www.healthcareoptions.ca.gov/doclib.asp

Comment: You can be a part of this landmark study designed to examine various reform options for extending health care coverage for California, and for the entire nation, since the results of this study will establish a rational basis for reform in all states.

If you are pleased with the status of health care in this nation, then ignore this message and go watch "John Q." If you believe that efforts must be made to improve our system, then you should participate in this process. It will require some work on your part. But this is finally an answer to the question heard at all health care reform meetings, "What can we do?" What we can do is make this effort to understand various alternatives for reform and then provide an informed input to the process. The various proposals are still being refined. The authors will consider all input during this process.

The remaining comments in this message may reflect my personal bias as a contributor to one of the options, the single payer proposal of James G. Kahn, et al, of the University of California at San Francisco (Kahn, Bodenheimer, Grumbach, Lingappa, Farey and McCanne).

Two single payer proposals (James Kahn, et al, and Judy Spelman) and a health service proposal (Ellen Shaffer) are unique in that they would provide comprehensive health services for everyone. The remaining proposals are best labeled "other proposals," although some might wish to call them "incremental." They are a mix of current concepts for expanding coverage, using a variety of mechanisms, resulting in significant differences in the degree to which they accomplish expanded coverage.

Of the "other" proposals, one that I would single out is the proposal of E. Richard Brown and Richard Kronick. Of the proposals that build on our current system, theirs is the most effective and most comprehensive of the choices. It introduces policies that would provide significant improvements in our dysfunctional system. It should appeal to many of those who insist that reform must be incremental, even though some might classify this as more than simply incremental.

But look at some of the reasons that the single payer and health service options should receive very serious consideration:

** They cover everyone.

** They include virtually all beneficial health care services.

** They effectively remove financial barriers to care, an increasing threat to access today.

** They establish equity in health care: equity in funding, equity in access, and equity in allocation of our health care resources.

** And for those that always want to know what the bottom line is in costs, the tentative analysis by John Sheils of The Lewin Group, presented at the symposium in Manhattan Beach on February 8, has demonstrated that all of the "other proposals" will increase health care costs, whereas the three universal proposals will decrease health care costs for California, by billions of dollars.

Although the project is not completed, one conclusion is already clearly evident. These proposals that reduce health care costs attain virtually all of the goals of an ethically-based health care system, whereas all of the proposals that fall short of these goals will increase health care costs.

The proponents of universal coverage should no longer tolerate being left out of the symposia, forums, press conferences, negotiating processes, foundation health care reform projects, or any other arena in which the future of our health care system is being debated. We should let the exclusive club of incrementalists know that we will accept invitations to join in on the process. But, in the absence of such civility, we should considering breaking down their doors. On behalf of all patients, present and future, our voice must be heard.

Don McCanne, M.D. President, Physicians for a National Health Program www.pnhp.org
don@mccanne.org

Robert Isman, DDS, MPH, responds to the California HCOP proposals:

One of the shortcomings of both your proposal and the one from Rick Brown and colleagues is that they both claim to be "comprehensive" in scope, yet neither deals comprehensively with dental services. In your proposal, at least according to the summary that was distributed at the public hearing held in Sacramento a couple of weeks ago, and not answered in direct questioning of Jim Kahn, dental and vision services appear to be almost an afterthought, and will be covered "as the budget allows." In the Brown et al. proposal, all health care coverage is said to be included for those who do not have current health coverage. The problem with that is that 1) children who would otherwise (i.e., by virtue of family income) be eligible for Healthy Families (California's SCHIP program), but who have medical insurance but not dental insurance are not eligible for Healthy Families, and presumably would also not be eligible for coverage under this plan; and 2) people covered by Medicare would not be covered by the Brown et al. proposal because they already have coverage, but Medicare does not include dental coverage.

Lack of dental coverage is the most pressing access problem in the US. For every child uninsured for medical care, there are 2.6 uninsured for dental care. About 30% of children who have medical coverage have no dental coverage. As most insurance is employment-based, when people retire, most are covered by Medicare, but as noted above, Medicare doesn't cover dental care. For every age group, access to needed dental care is cited as a reason for unmet health care needs several times more frequently than access to needed medical care, prescriptions, glasses, or mental health care.

We need to stop looking at insuring different parts of the body with different types of coverage. This situation is perhaps best captured in a statement made by the Coalition for Oral Health during hearings on the ill-fated Clinton health plan:

"Imagine waking up one morning with an excruciating pain in your hand, going to your physician, and having her tell you that you have an abscess on one of your fingers. 'I can treat it,' she says, 'but I'm afraid your health insurance won't cover it. They don't cover finger problems.' Most of us would think this was a pretty strange form of health insurance. If, as most of us now believe, exclusions based on pre-existing conditions, age, and occupational category are wrong, why should we accept exclusions based on parts of the body?

"That is exactly the situation that exists today with respect to oral health care. The mouth is not considered part of the body. While we would be appalled at excluding limbs and organs from coverage, we seem to accept most casually the exclusion of the entire human mouth. If you have an abscess on your leg, your arm--even your face--no problem, you're covered. If that abscess happens to be in your mouth, inches from your brain, you're out of luck. This is not rational."

Comment: Jim Kahn's silence in response to the question about dental coverage is similar to the long period of silence by Jack Benny when asked during a holdup, "Your money or your life?"

After being asked a second time, he responded, "I'm thinking, I'm thinking!"

Well, Jim was thinking, and he brought the dental and eye care issues back to his writing team. Dr. Isman's comments are deeply appreciated. He can be assured that Dr. Kahn's team is revisiting this extremely important health care issue.

Not only does the California Health Care Options Project provide a spectrum of reform proposals, it also provides mechanisms for public input, both through the symposia such as the one in Sacramento mentioned by Dr. Isman, and through the process for public comment mentioned in the earlier message. This time, the public really does have input into the process. Do not miss this opportunity to be a part of the process.

http://www.healthcareoptions.ca.gov/

Posted by pnhp at 12:00 PM | Permalink | Comments (0)

Gloucester Daily Times
February 6, 2002

"Any politician who supports a tax cut should be arrested, convicted and sentenced to a minimum wage job, ideally a job that has no health insurance. If the politician has a spouse and children, they will probably find themselves eating a meal or two at a soup kitchen and applying for food stamps. They will probably have to visit the local emergency room for routine health care. They will end up praying that their car doesn't break down, if they can even afford to keep a car on the road. They will suffer indignity, anxiety and hopelessness.

"Voters who support tax cuts and then complain about lousy roads, high housing prices, poor service in deregulated industries such as airlines and cable television, high health care costs and skyrocketing college tuition payments should be arrested, convicted and sentenced to working at a drug clinic. There, they will see real people fighting for their lives to overcome bad choices, mental illness and lack of opportunity. They will realize, it is hoped, that there is not much that separates the haves from the have nots in today's America."

"When did America become so cruel? How did our spiritual health become so detached from our material wealth? Is this really the America that Americans want?"

http://www.gloucestertimes.com/

Comment: For those who believe that this must be a emotional expression of the views of an ultraliberal publisher, you should be aware that the Gloucester Daily Times is owned by Dow Jones & Co., Inc.

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The Lancet 2002; 359: 520-22 February 9, 2002

CHARTER ON MEDICAL PROFESSIONALISM

Excerpt:

"Commitment to improving access to care"

"Medical professionalism demands that the objective of all health-care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession."

http://image.thelancet.com/extras/10522web.pdf

Comment: This Charter, which has been labeled "the modern update of the Hippocratic Oath," was prepared by representatives of the European Federation of Internal Medicine, the American College of Physicians -American Society of Internal Medicine Foundation, and the American Board of Internal Medicine Foundation. It is a call to physicians to reaffirm their active dedication to principles of professionalism.

Professionalism dictates that physicians must strive to eliminate barriers to equitable health care. In the United States, our flawed health care financing creates the greatest barrier to care. It is imperative that we enact reform that eliminates financial barriers thereby providing a system in which other inequities can be more readily addressed. It is not a choice between supporting the self-interests of the business of medicine and the professionalism implicit in supporting health care equity, but rather it is placing professionalism first and then tailoring the business of medicine to fulfill the ideals of the profession.

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CDC National Center for Health Statistics HHS News
February 4, 2002

"In 2001, 4.8 percent of the population--up slightly over the past four years-- was unable to obtain needed medical care in the past year due to financial barriers."

http://www.cdc.gov/nchs/releases/02news/healthinsur.htm

Comment: Fortunately, most people are relatively healthy and have only nominal health care needs. For those that do need health care, nearly one out of twenty, over 13 million people, were unable to obtain care simply due to the lack of a comprehensive system that equitably funds health care. A significant proportion of those that did not need care still lacked the security that would be provided by such a system, even though they may not have realized it.

How can the wealthiest nation on earth shut the door on 13 million people that already need health care? How can the wealthiest nation on earth fail to assure health security for an even greater number of individuals that eventually also will need health care? Have we no sense of solidarity?

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The Washington Post
February 3, 2002
By Mitchell E. Daniels Jr., Director of the Office of Management and Budget

"To the average citizen, shifting resources when priorities change makes simple common sense. When the new priority is the survival of Americans, the cause is even more obvious, a straightforward matter of battle stations vs. business-as-usual.

"But Washington is a capital overrun by vested interests whose livelihoods depend on extracting ever-increasing quantities of taxpayer dollars for their narrow causes. It is not clear that they will subordinate their interests even to the needs of wartime."

"The budget debate ahead will measure our wisdom and our will to respond to this latest lethal threat to American lives and liberty. But it will also test our maturity as a democracy, our ability to put first things first... "

http://www.washingtonpost.com/wp-dyn/articles/A11718-2002Feb1.html

Comment: The Bush administration has placed a great emphasis on testing. Can we pass the test of our maturity as a democracy by putting first things first? Or are we about to fail this one?

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Uwe Reinhardt, Ph.D., James Madison Professor of Political Economy, Princeton University:

"Teachers, mothers and government are the foundation of the nation's wealth."

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HHS Press Release
January 31, 2002
"Would Allow Use of Existing Resources to Expand Prenatal Care Immediately"

"HHS Secretary Tommy G. Thompson announced today that he plans to issue a proposed regulation soon allowing states to provide health care insurance coverage under the State Children's Health Insurance Program (SCHIP) to pregnant women for their children who are not yet born."

"The new regulation would clarify that states may include coverage for children from conception to age 19. This would mean that pregnant women can receive prenatal and delivery care."

HHS Secretary Tommy G. Thompson:

"Prenatal care for women and their babies is a crucial part of the medical care every person should have through the course of their life cycle. Prenatal services can be a vital, life-long determinant of health, and we should do everything we can to make this care available for all pregnant women. It is one of the most important investments we can make for the long-term good health of our nation."

http://www.usnewswire.com/topnews/temp/0131-118.html

Comment: You cannot be exposed to any news source this morning without hearing about the controversial nature of this benign-appearing announcement. Changing the legal status of a fetus, with its controversial implications, is cloaked by this program that would expand prenatal coverage, obviously a desirable goal.

But there is an even more ominous feature of this proposal. The flurry of activity by the media demonstrates the concern. Efforts to seriously address the number one health care problem today, the uninsured and under-insured, have been almost completely left off of the radar screens of the media. Instead, attention has been directed to much less important issues such as the patient bill of rights, or disputes over tax credits or defined contribution approaches. It is not that these issues aren't important, but by directing attention to these issues, the politicians and the insurance industry have managed to dodge the real issue that must be addressed immediately - the plight of the uninsured. Unfortunately, the Bush administration has elected to throw this new bone out to the media to occupy them with this issue that will sell their information products, but with the great advantage of continuing the deception that these are the real issues, while the uninsured are left on the back burner.

On this one, the media must carry much of the blame. The public does not understand the scale of the terrible health care injustices taking place today. They do not understand the degree of waste of their health care resources. They do not understand that policy decisions can be made that could provide equity in access and coverage for comprehensive services for everyone, paid for merely by introducing administrative efficiencies, while returning to patients free choice of health care providers. The media have a moral responsibility to inform the public of the severity of the problems with our health care system, and the real options for reform. But then, covering a hissing cat fight over whether a fetus has rights sells better. And, like the private health plans, the media is placing profit over patients.

Beth Capell, Ph.D., of Health Access, responds to the message on insurers creating multi-tiered access to hospitals:

"If poor people needed health care, they would have it. It is plainly a luxury afforded only to the wealthy and healthy.

"California State Senate President Pro Tem John Burton once introduced legislation to make it a crime to be poor. We probably need to amend this to include needing health care."

Uwe Reinhardt, Ph.D., of Princeton University, responds to Dr. Capell's comments on health care being a luxury afforded to the wealthy:

Well, we do ration justice by ability to pay, and education as well. It is only natural that we shall do the same in health care.

In fact, health care could be viewed the odd-one out in our scheme of things, but only for a few decades after WWII. The post WWII decades were, in the main, an aberration from our nation's ingrained, class-based approach to the distribution of human services. After having gone through the Depression and WWII, our grandparents probably began to appreciate the virtues of a Rawlsian society--a so-called socialist market economy. The Baby Boomers and their issue, the GenXers, have few such sentiments (unless they themselves are in a pickle). Close your eyes and ask yourself this question:

A year ago, when Enron was still sailing high, would its proud employees not have spat at people who shill for universal national health insurance? Now they cry into the TV set every night, ruining my supper. As I have said before, I have zero compassion for them.

We are inexorably marching toward a society in which the best advice one can give young people is this: Forget serving the nation. Before you do that, first get rich. Then you have the leisure of serving the nation, if you still wish it.

Of course, our youngest thumbed his nose at his Dad's sage advice. He is in the Marines. I admire his guts, but I did warn him loudly that this nation will never thank him for the sacrifices and risks he is taking on his shoulders. He will be respected only if he gets well to do. Still, he went. You go figure.

Best

Uwe

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