News

By Matt Leingang
Democrat and Chronicle

(March 26, 2003) — A certain realization comes over medical students during their training, argues Corey Fehnel, a first-year medical student at the University of Rochester.

“You see how fragmented the payment system is in health care, and you realize that it’s not sustainable,” says Fehnel, 24. “There are too many questions about who has insurance, who doesn’t and how that affects quality of care.”

The solution, Fehnel argues, is a single-payer health care system for the United States, and he’ll lead a rally for it at 5:30 p.m. Thursday at the UR Medical Center’s Flaum Atrium. Some veteran physicians in the Rochester community are also expected to lend their support.

Fehnel is a member of the American Medical Student Association, which has long advocated national health insurance.

Congress has remained largely deadlocked for years over how to approach reforms to the U.S. system, where costs continue to rise at more than 10 percent each year and more and more consumers find themselves unable to afford private health insurance premiums.

About 41 million Americans lack health insurance.

Patchwork reforms won’t work, Fehnel says.

The AMSA single-payer plan calls for the federal government to finance health care, but it leaves the delivery of health care to mostly private control.

Patients would have their choice of provider; physicians would no longer be constrained by a patient’s insurance status; hospital revenue would be more stable; and much of the bureaucracy needed for handling the dizzying array of private insurance plans would be eliminated.

“There’s no question, based on the Canadian experience with a single-payer system, that health care that is financed and delivered this way is far cheaper and less confusing to consumers,” says Dr. Kevin Fiscella, a family practitioner in Rochester who will attend Thursday’s rally.

The downside of a single-payer system, critics argue, is that thousands of people who work in the insurance industry would lose their jobs, and politicians would be left in control of deciding which hospitals would get funding for new technology and other capital improvements.

Questions of quality -- long waits for specialty services, such as CAT scans and MRIs -- also dog the Canadian system.

No system is absolutely perfect, but lessons can be learned from Canada about how the United States can develop a single-payer plan that ensures both low cost and high quality for everyone, Fiscella says.

http://www.democratandchronicle.com/news/forprint/0326story8_news.shtml

Posted by pnhp at 09:16 AM | Permalink

American Academy of Family Physicians
Press release
March 20, 2003
Medical Student Interest in Primary Care Continues to Decline

In the United States, graduating medical school seniors pursuing careers as doctors are more apt to choose a non-primary care specialty in 2003. Preliminary information released today by the National Resident Matching Program indicates that the 2003 initial fill rate for family practice residency programs is 76.2 percent or 2,239 positions filled out of 2,940 positions offered. This represents a 5 percent decrease from last year's initial fill rate and continues a six-year trend that began in 1997.

James C. Martin, M.D., FAAFP, President, AAFP:

"This continuing decline in the number of future family physicians will be devastating to the health of the American people. Family doctors conduct almost 200 million office visits each year - that's 75 million more visits than any other medical specialty. Family physicians are the backbone of the American health system."

"The current U.S. health care system does not appropriately value the essential function of family physicians. This undervaluation is especially apparent in two areas: the system's inadequate reimbursement for patient services, including those provided by the federal government to Medicare patients, and a negative medical school educational environment."

"The AAFP identified this trend of declining fill rates for family medicine more than five years ago and funded major studies from 1998 to 2000 at the University of Arizona, Tucson, to determine the cause."

"Results of the Arizona University studies indicate that medical schools need to address the important role the following factors play in whether medical students pursue a family practice residency: medical school admissions policies, poor faculty role models, and a medical school culture prone to disparaging family medicine. Initial results from the FFM research point to extraordinary hours worked for inadequate reimbursement, a limited scope of practice, and the general feeling that family physicians, with their breadth of training, are not as highly valued as a sub-specialist with a very narrow scope of practice."

"With the health care needs of millions of Americans at stake, our medical schools must provide a positive training environment for future family physicians. The federal government can help by supporting programs that enhance medical school and residency educational efforts, and patient care initiatives. Such support would require a reversal of current proposed budget cuts - the Bush Administration's proposed 2004 budget slashes federal funding for primary care training programs by an alarming 96.28 percent. These are the only federally funded programs designed to address the shortage of primary care physicians in America."

"As noted by Barbara Starfield, M.D., M.P.H., 'There is no longer any doubt of the importance of primary care as the key to an effective and efficient health service. In a major cross-national comparison..., countries with strong primary care systems were found to have lower health care costs than those countries with weaker primary care infrastructures... States in the U.S. that have more primary care resources have better health outcomes for just those indicators that would be expected to respond to primary care alone, even when income inequalities within the states are taken into account.'"

http://www.aafp.org/x20089.xml

Comment: This problem should not be formulated as a conflict between specialization and primary care. Specialized care has its own set of issues which include proper allocation of our finite resources, access to advanced technologies, fragmentation of services, inequitable compensation, isolation from the rapidly expanding body of knowledge in general medicine, and other deficiencies that can result from being isolated in a small niche of medicine. An integrated health care system can more readily address these issues, providing guidelines to improve the role of specialists within the global health care system.

On the separate issue of primary care, Dr. Starfield is absolutely correct when she states, 'There is no longer any doubt of the importance of primary care as the key to an effective and efficient health service." Every effort must be made to sustain the primary care fields, including family physicians, general internists, pediatricians, nurse practitioners and, in some instances, obstetrician-gynecologists. Once we are ready to transform into an integrated system we must have in place the substrate and foundation of a primary care system.

As a first step, we should adopt a universal, publicly-administered system of funding health care. Under the single payer model, regional allocation of our resources would ensure the support a strong primary care system.

Don McCanne, M.D., FAAFP Charter Fellow, American Academy of Family Physicians Charter Diplomate, American Board of Family Practice Life Member, American Academy of Family Physicians

(Although I have revealed my past bias for family practice, my current bias in my work on health care reform is for an affordable, efficient, effective, accessible, high-quality, universal health care system. That system needs a strong primary care base supported by appropriate specialized services.)

Posted by pnhp at 11:28 AM | Permalink

Robar held key roles at SDC, moved well between cultures

By AMY RABIDEAU SILVERS
asilvers@journalsentinel.com

Last Updated: Nov. 2, 2002

Audrey Robar, a longtime community activist, died of an apparent heart attack while trying to decide whether to call for medical help.

Robar had worked at the Social Development Commission until Sept. 9. Her health insurance had expired at the end of September. Robar had found a part-time job with benefits but had not yet decided whether to begin paying the cost of temporary insurance.

She was 63.

After a couple weeks of being unable to shake cold symptoms, Robar began to feel much worse Oct. 23. She called a sister, Aldene Egan, after 4:30 a.m.

"I've got this pulling in the muscles across my chest and my arms," Robar said, according to her sister.

Egan told her that it sounded like a heart attack and that she should call 911 right away.

"But I don't have any insurance," Robar said.

Robar went to get her paperwork, then told her sister she felt dizziness and pain in her neck.

Egan heard her sister fall and the sound of her gasping for breath. Then there was silence.

Egan hung up and called for help. Emergency personnel broke the door down at Robar's northwest side home. Efforts to revive her failed.

Robar worked for the SDC twice, for a total of 18 years, most recently since 1996. In 1999, she was promoted from manager in the education, employment and training department to director of research, planning and evaluation, reporting to executive director Deborah Blanks.

"I don't think anyone at that agency could give more than Audrey did," said Norma Madison, a friend from SDC who now is with the Milwaukee Urban League.

Friends said Robar was relieved to have landed a new job and planned to start Nov. 1.

Janice Wilberg, an elected commissioner with the SDC, said she knew Robar for 20 years in Robar's many community roles.

"She worked in the Hispanic community, the African-American community," Wilberg said. "She had an emerging role in the Hmong community. She was all over the map. . . . She could cross all this cultural junk that traps other people.

"She just had a lot of energy. She was tireless. She never did it for the pay - she sure never did it for the pay. She just put her shoulder to the wheel and did it."

Robar, born in Milwaukee, was the second of seven children. She would sometimes share stories of poverty during her own childhood. Her father, often absent, moved the family around the Midwest. For years, they lived without any kind of permanent shelter, often without water or electricity.

Once her father built a sort of house on the back of a flatbed truck. At other times, the family lived in a makeshift trailer, an Army barracks bus and a tent.

"That was where she got her intuition and inspiration," said daughter Alice Orlich, of her mother's work with the poor.

Robar's mother eventually returned with the children to Milwaukee, where Robar graduated from South Division High School.

She began working with community programs, earning an undergraduate degree in community education from the University of Wisconsin-Milwaukee and later a master's degree, also from UWM. Positions included working in leadership with the Bay View Community Center and Career Youth Development, and with the board for the Sixteenth Street Community Health Center.

Robar and her husband, Sam Orlich, divorced in 1972. She is survived by daughters Eva Robar-Orlich and Alice Orlich; son Sam Orlich; mother Alice Kowalski; sisters Aldene Egan and Arlene Zakhar; and brothers Alfred, Arlen and Allen Robar.

A memorial gathering will be from 5 to 9 p.m. Monday at Milwaukee Friends Meeting house, 3224 N. Gordon Place. A service will begin at 7 p.m.

A version of this story appeared in the Milwaukee Journal Sentinel on Nov. 3, 2002.

http://www.jsonline.com/news/nobits/nov02/92735.asp

Posted by pnhp at 11:17 AM | Permalink

(In reading today's quote, please ignore the deficiencies of a verbatim transcript of a spontaneous response given during the Q&A segment of the presentation, but concentrate instead on the message.)

Alliance for Health Reform March 21, 2003 Washington, DC

"Dynamics of the Uninsured"

ED HOWARD: Let me just ask each of our panel members if we don't have any other questions from the floor if they care to take about 30 seconds and sum up what you think folks ought to take away from this discussion. We have a budget resolution that's making its way through at least one House of the Congress and probably the other House soon at least in some iterations it will have some money that is intended to address the problems of folks without insurance. How should that money get spent? How should we apply it to this discussion that we're having this afternoon? And what next steps ought to be at the highest priority in that context? Or you can tell us anything else you want.

PAMELA FARLEY SHORT, Ph.D., Professor of Health Policy and Administration and Director, Center for Health Care and Policy Research, Penn State: Well I guess one idea or thought that I'd like to share and I haven't had a chance to share so far is just that to say that one of the things that seems to me is really lacking in our patchwork kind of system of health insurance is a source of coverage that's reasonably priced and that people can hang onto as their personal circumstances change. So whether - and that is an impediment to - it complicates the issue and the problem of using almost any kind of financing strategy for example if we have tax credits you still have the problem of where are people going to buy reasonably priced insurance on terms that are just not as favorable as large employers offer at least closer to that than people can buy on the individual market. So one of the reasons why there's so much turning and so much turnover is that there really is no place that people can be insured as their incomes go up and down particularly as their incomes kind of float around some eligibility limit so that if we had whether it be and there are lots of different ideas on the table as to what such a universal source of individual health insurance might be ranging from expanding and allowing people to buy into public programs of Medicaid or Medicare at older age levels, purchasing cooperatives, the federal employees plan, the state employees plans and there's a lot of ideas about what that might be but at the moment nothing like that exists and so what happens is that as soon as people's income goes up so that the state will know and the federal government will no longer pay for them to have coverage for Medicaid they have to leave that source of coverage and find another it's not and if we could move towards the direction of some of a system where the coverage could stay put you just are covered from a given place and you keep that plan and your kids they're covered with you but what changes as your circumstances change is who's paying for it and that may be a way of getting ourselves out of some of the problems that we currently confront so that as your income rises you pay more, if you have a job your employer doesn't necessarily provide you with the coverage but pays into you know contributes towards your coverage you know this is kind of a system that you know in essence union employees have that sort of situation because their jobs change so much and maybe if we could figure out a way to get a place that everybody could buy then almost any financing strategy from you know tax credits to buying it yourself even for those high income people would be a lot easier.

http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=806

Comment: There is growing recognition that the pool of uninsured is not a single relatively stable (though expanding) group of individuals. In fact, it is quite unstable as individuals rotate in and out of various programs based on eligibility or ability to pay. Change in employment status changes eligibility for employer-sponsored programs. Moving in and out of poverty status changes eligibility for public programs for low-income individuals. Change in health status affects eligibility for individual coverage. Change in age affects eligibility for SCHIP or Medicare coverage.

Dr. Short is quite correct. We need an affordable, comprehensive health insurance product that will always be ours, regardless of employment status, health, age, income level, or any other arbitrary determinant of insurance eligibility. But which insurer will offer that kind of product?

Why is there a deafening silence in response to this question?

It's quite clear that only a universal, public-insurance program can ever fill that bill. Once we accept this principle, it would be very easy to develop a strategy for equitably financing the system.

Posted by pnhp at 12:32 PM | Permalink

Washington Post
March 24, 2003
Bethlehem Retirees' Benefits to End
By Adam Geller

Company-paid health benefits for 30,000 white-collar Bethlehem Steel retirees will end this month, after a bankruptcy judge Monday rejected a request to extend coverage through April.

Instead of the extension, the court approved an arrangement that might offer both union and salaried retirees reimbursement for two weeks of medical insurance.

The United Steelworkers of America, which represents retirees from union ranks, has already agreed to a deal that will see their members lose health insurance after March 31.

But a lawyer representing white-collar retirees argued that they needed more time, and would not have the benefit of alternative health insurance the union may be able to arrange for its retirees.

A. Dennis Terrell, the attorney for the salaried retirees:

"We have a lot of old people who don't know what to do. They need time to figure out what to do."

http://www.washingtonpost.com/wp-dyn/articles/A20447-2003Mar24.html

Comment: Play or pay, employer-mandate models of reform are receiving support from a broad range of interests. But is this really what we want? Instead of being left stranded, not knowing what to do, these retirees could have been in a universal public program and would never have had to face their current dilemma.

Isn't it time to provide permanent health security for everyone by establishing our own public program of universal insurance? We can afford it. What's stopping us?

Posted by pnhp at 11:36 AM | Permalink

Chicago Tribune
March 23, 2003
Seniors spurning pilot Medicare PPO effort
By Bruce Japsen

A new and highly touted Bush administration effort to help Medicare patients pay for prescription drugs is a bust so far.

Three months into a much-anticipated pilot program, less than 1 percent of the elderly and disabled Medicare recipients eligible have signed up.

The initiative targeted up to 11 million Medicare patients in 23 states... to sign up for preferred provider organizations (PPOs).

Unlike health maintenance organizations, PPOs allow subscribers to visit doctors outside of their networks, a key reason they have become the most popular health plan.

The Bush administration figured the PPOs' popularity would mean that the pilot program would go over well with the elderly and disabled covered under the federal Medicare health insurance program.

On its face, the premium charged by the PPO seems like a bargain. The monthly charge is between $40 and $75 on top of the $58.70 monthly Medicare premium.

In contrast, most seniors who want prescription coverage have to buy supplemental policies priced at $200 or more a month, join an HMO that restricts their choices or pay out of their own pocket.

Why the lack of enthusiasm?

Among other things, most PPO plans do not cover the latest and typically more expensive brand-name prescriptions some seniors say their doctors are prescribing. They do pay for generic versions of brand-name drugs, but sometimes those versions are not yet available.

The fact that seniors have not embraced the pilot could be a setback for Bush health advisers who saw the program expanding to cover even more of the nation's 40 million Medicare patients in health plans operated by private companies.

For now, Bush official Scully says, the PPO pilot is budget neutral, using existing Medicare funds that prevent the plans from offering brand-name coverage. Should Congress pass the president's reform bill, Scully said, plans would compete for a larger chunk of money, and a much richer benefit with brand-name coverage will be available.

Tom Scully, administrator for the Centers for Medicare & Medicaid Services:

"The health plans need to do a better job of marketing because the only way you get people to switch is through a lot of marketing."

http://www.chicagotribune.com/business/chi-0303230063mar23,1,4556174.story

Comment: Question of the day: How many red flags can you count here?

A very fundamental flaw in the Bush administration's reasoning is that PPOs in the private market were not chosen because of their popularity, but rather they were chosen when the indemnity plans were withdrawn from the market and individuals were left with a choice of PPOs or HMOs. Although integrated HMOs such as Kaiser remain popular, network middleman HMOs ultimately have proven to be less popular than PPOs since the HMOs have been more restrictive and less dependable. Patients do prefer to have the greater choice of providers that PPOs offer compared to HMOs, with the added option of obtaining care outside of the provider list even though with increased cost sharing.

The primary advantage that PPOs offer over indemnity plans is that PPOs contract rates with providers, theoretically controlling costs. But once the market is saturated with PPOs (and HMOs), rates must reflect the true costs of delivering care plus a modest profit or the health care market will collapse. Ironically, Medicare also "contracts" rates with providers, but without the need to have restrictive provider lists since non-contracted providers must still adhere to Medicare-dictated rates (with a minor adjustment). Thus if benefits and cost sharing in the PPOs and traditional Medicare were comparable, there would be absolutely no reason to choose a PPO, because of the restrictive provider lists and the greater administrative waste (with the need to increase beneficiary cost sharing).

The reason that the PPOs in this pilot program are not selling well is that the program is "budget neutral." Since the PPOs receive the same reimbursement as the costs in the traditional Medicare program, not only do they have to target their marketing to a healthy subset of Medicare beneficiaries, they also must be certain that their prescription drug "carrot" used to entice patients is a very low-cost (Spartan) program. Medicare beneficiaries recognize the inadequacies of these minimal prescription plans and do not want to give up their free choice of providers in exchange for this very minimal benefit.

Tom Scully suggests that the problem is inadequate marketing on the part of the plans. He certainly exposes his blind faith in the market when he suggests that an inferior product needs only the blessing of Madison Avenue to displace our popular Medicare program.

Particularly disconcerting is the fact that Scully states that, under the president's reform bill, plans would "compete for a larger chunk on money" for more generous prescription coverage. The president's plan for traditional Medicare offers only negligible prescription benefits (nearly worthless discount cards, $600 maximum for poverty-level beneficiaries, and an approximately $6000 deductible catastrophic coverage for the wealthy). Scully's comments suggest that the administration is willing to pay more to the plans than the amount allocated for the traditional program. That certainly belies their claim that the private plans will reduce costs.

Why should taxpayers support more expensive private plans while being denied prescription coverage in our own public Medicare program? The least expensive solution that would provide comprehensive prescription coverage for everyone would be to add it as a benefit to our traditional Medicare program.

Posted by pnhp at 02:07 PM | Permalink

Tim Radford Denver

The US health system is itself sick and needs a national commission to get it back on the road to recovery, Floyd Bloom, president of the American Association for the Advancement of Science, told the association’s annual meeting last week.

Dr Bloom is the head of neuropharmacology at the Scripps Research Institute, La Jolla, California. He was editor in chief, until 2000, of the journal Science, and he once headed the neuropharmacology laboratory at the National Institutes of Health. That an architect of modern neuroscience chose to open the largest single public science conference in the United States to make his point suggests more than just a cautionary diagnosis.

Dr Bloom warned of soaring health premiums, shortages of expertise in a number of specialties, paperwork burdens, and archaic methods of information management. And he had more immediate problems in mind. "The threat of war and the imposition of mass casualties from any new acts of terrorism could prove calamitous for the US medical community’s ability to care for the ill," he said.

He listed specific problems. Communication was difficult. The number of drugs available to treat an increasingly elderly population had passed the 10 000 mark. Many of these drugs had covert interactions between them. Patients were seeing several doctors, who did not know about each other and who were prescribing drugs that may be mutually antagonistic or toxic.

"So there is a great need for stepping back from this crisis situation and finding ways to re-examine the decisions that we have made and the choices that we have in the future," he said. "Unless we do something now, all of the doubling of the NIH’s [National Institutes of Health] research resources . . . will have a difficult time making it through the pipeline to reach the bedsides of the patients," he said. Genomic research was unlikely to provide any dramatic benefits for many years, but it distracted from the problems multiplying right now.

He also raised the problems that stress in infancy might impose in later life for millions of Americans. "Stress is the name we give to a natural reaction our bodies generate when we encounter a situation that is unbeknownst to us," he said. "We activate our autonomic nervous system, and as a result our blood pressure goes up, our heart rate goes up, our blood glucose goes up, and our blood lipids go up. All of which is a great advantage if you are trying to flee from a threatening situation.

"But if stress is maintained, what results is a change in our metabolism which permanently results in hyperglycaemia, down-regulation of insulin receptors, deposits of lipids from those high lipids in the bloods into the endothelial cells of the capillaries. And prolonged stress of itself is a major factor in the onset of type 2 diabetes, hypertension, cardiovascular illness, and various problems of modern society."

He then turned his attention to what he described as the "reactive" health system in the United States.

"We wait until somebody is sick, and then we try to do something about it. Preventive medicine has a great deal to offer. Socioeconomic status has important proclivities for a host of illnesses in our country, including osteoarthritis. The lower you are in the socioeconomic status scale, the more likely you are to have osteoarthritis, or asthma, or other kinds of pulmonary illnesses," he said.

"We can’t declare poverty to be gone. But we can recognise what the factors are and try to apply what we have today—instead of waiting for molecular discoveries to tell us how we might tailor drugs at some point in the future."

Tim Radford is science editor of the Guardian.

http://bmj.com/cgi/content/full/326/7386/416/b?eaf?eaf

Posted by pnhp at 01:42 PM | Permalink

Kaiser Commission on Medicaid and the Uninsured
March 2003
The New Middle-Class of Uninsured Americans - Is it Real?
by John Holahan, Catherine Hoffman, and Marie Wang

Summary

We conclude that data from the Census Bureau's 2002 annual report Health Insurance Coverage: 2001 has been misinterpreted when the majority of the newly uninsured are characterized as either middle- or high-income people. Using household income brackets that do not account for the composition of the household or the effect of general inflation on income when studying changes over time can create misunderstanding about who the uninsured are, as well as the effectiveness of different policy options intended to decrease the number of uninsured.

While we found that the number of high-income uninsured (400%+ of poverty or $56,512 for a family of three in 2001) grew by about 300,000 due to a loss of employer-sponsored coverage, this is substantially less than unadjusted data from the Census Bureau's report might indicate. We also found nearly a 300,000 decline in the number of middle-income Americans who lacked health insurance, largely because there were 800,000 fewer middle-income Americans. Many middle-income Americans lost jobs and/or income, contributing to the substantial increase in the number of people with incomes below 200% of the poverty level-where the likelihood of employer-sponsored coverage is much lower and uninsured rates are much higher. Most of the growth (1.3 million) in the uninsured was borne by low-income Americans with incomes less than 200% of the poverty level.

http://www.kff.org/content/2003/4090/4090.pdf

Comment: The tenor of this report seems to indicate that it is reassuring that the increase in the numbers of uninsured has been primarily in the low-income sector, and not in the middle- and high-income sectors as previously reported based on unadjusted Census Bureau data. Rather than a decline in the rate of insurance in the middle-income sector, there has been a decline in income with a large shift to the low-income sector and a concomitant loss of employer-sponsored coverage. The obvious conclusion is that many middle-income Americans not only lost their insurance, but they also lost their incomes - doubly bad news.

The authors make the point that this difference is important from a policy perspective. Generally, many employers of low-income individuals do not have adequate financial resources to provide insurance coverage for their employees. Studies of tax credits and association health plans indicate that they would fall far short of the need. Thus, policies designed to enhance public programs for low-income individuals seem to be in order. If so, we should be increasing eligibility and funding for these programs, especially Medicaid. But the exact opposite is taking place.

We simply won't get it right until we are prepared to accept the fact that we desperately need to pool all of our existing resources into one publicly-administered program. That would work just fine for all of us.

Posted by pnhp at 10:24 AM | Permalink

The Boston Globe
3/21/2003
Editorial
The Medicare cure

The Bush administration is so eager to shift Medicare recipients into HMOs that one might assume private insurers have a better record than Medicare at curbing the growth in health costs. In fact, neither the government insurance program for the elderly nor the private sector has excelled at holding down costs, but a recent report found that Medicare does a substantially better job than the insurers.

(Also)... a 2002 study... found that Medicare beneficiaries are generally more satisfied with their health care than are privately insured people under age 65.

So the question remains: Why would the Bush administration be encouraging Medicare recipients to join HMOs by offering them better prescription-drug benefits than they would get under a plan for those who stay in Medicare?

The answer is that the administration knows there is great popular pressure to add a prescription drug benefit to Medicare. If this were done through the traditional Medicare program, it would give government enormous buying power to drive down drug prices with the pharmaceutical companies. Splitting off Medicare recipients into smaller HMOs addresses one of the drug industry's great fears: that a single agency with the power of the entire Medicare population would be able to force down the exorbitant prices now charged for many essential medicines.

A healthy pharmaceutical industry is crucial to progress in developing life-saving drugs. But at a time when hospitals, doctors, and Medicare recipients themselves have had to make sacrifices, the drug industry should do its part, too. The Health Affairs report makes a strong argument for putting a drug benefit right where it belongs, in Medicare, with its superior record of controlling costs and satisfying its beneficiaries.

http://www.boston.com/dailyglobe2/080/editorials/The_Medicare_cure+.shtml

Comment: The primary goal of the Bush administration is to reduce public (tax) funding of the Medicare program. Strengthening Medicare with a bona fide prescription benefit would complicate that task because public support of our program of social insurance would be even greater. But the Bush administration also supports policies that greatly benefit their friends in the insurance and pharmaceutical industries.

The Boston Globe is quite correct with its comments on this one aspect of the complex Medicare issue. All other providers of health care services to Medicare beneficiaries must comply with the restrictions that the program places on allowable charges - charges that attempt to be both fair to the providers and fair to the taxpayers. Since pharmaceuticals have become a greater component of health services, it has become imperative that this industry also comply with the same standards of fairness. By making pharmaceuticals a full benefit of Medicare, the government will be in a position to set allowable charges, based on fairness to all.

Posted by pnhp at 10:22 AM | Permalink

Monterey County - The Herald
Mar 21, 2003
Doctors lament Natividad woes
By Joe Livernois

Dr. Pedro Moreno is frustrated.

Among the hundreds of patients he sees as a family practice physician at Natividad Medical Center is a 35-year-old man diagnosed with diabetes two years ago.

But the patient can't afford the $50 monitor he needs to check his blood sugar. He can't even afford the $4 to buy the test strips to place in the monitor.

"I haven't been able to get him the care he needs," said Moreno. "I feel completely powerless."

Moreno and other doctors at Natividad Medical Center are hitting the streets to discuss the problems suffered by uninsured patients -- and the problems the rest of society encounters because of the health-care crisis.

Natividad Medical Center, the county-operated hospital in Salinas, provides much of the health care to many of the approximately 80,000 Monterey County residents who are uninsured and the thousands of others covered by the state Medi-Cal program.

Natividad itself is in serious financial trouble and is expected to end its fiscal year with a $13 million operating deficit. On Tuesday, the Board of Supervisors will hold a public hearing on a proposal to close two clinics in Salinas affiliated with Natividad.

Moreno said the problems at Natividad are aggravated by the lack of insurance coverage. And he said the problems will only get worse for uninsured residents if the county is forced to shut down clinics or cut services at the county hospital.

The drain on Natividad is worsened because uninsured patients are flooding the hospital's emergency room because they can't afford to see regular physicians or specialists, (Dr. Marc) Tunzi said.

Moreno urged about 75 people at the Latino Network luncheon to lobby legislators to support national and state health-care reform proposals, including a single-payer insurance program now being consider by state Legislators.

http://www.montereyherald.com/mld/montereyherald/news/local/5448148.htm

Comment: The threat to the safety-net infrastructure is greater than ever. We can no longer dismiss the growing numbers of uninsured because, "They can go to County."

Dr. Moreno clearly understands. The solution is comprehensive reform of health care funding through a single-payer insurance program.

Posted by pnhp at 10:19 AM | Permalink

Star-Telegram
Mar. 16, 2003
Indigent care network envisioned
By Mitch Mitchell

A new group, the Healthy Communities Coalition, has been working for two years to develop a plan to organize the loose network of health care workers who help Denton County's poor.

Coalition members maintain that creating a structured system would mean that the work could be spread out among a larger group of physicians. It would also mean that indigent patients would have a better chance of receiving care from a physician they knew, instead of being shunted from clinic to clinic, from emergency room to emergency room.

The Healthy Communities Coalition may consider the establishment of a network of clinics throughout Denton County, but the costs make that option unlikely, officials said.

Financial concerns also make it unlikely that a partnership to care for Denton County's indigent could be forged between Denton County and an adjacent county, such as Tarrant or Dallas, that has a public hospital.

Coalition members are searching the Federal Register and state funding sources for available grants but have found none so far. Meanwhile, providing health care for poor and uninsured people in Denton County has been financially taxing for all who are involved.

But members of the Healthy Communities Coalition contend that they can improve access to health care for Denton County and that all they need is a little time and money and a finished plan. The alternative is doing nothing while watching the system become more haphazard.

http://www.dfw.com/mld/dfw/5406354.htm

Comment: Futility. This noble effort, taking place in many regions in the country, to establish a voluntary network providing access to health care for the indigent, is doomed to failure because of the crisis in health care funding. Those willing to provide enough care to meet the need are no longer able to fund their losses by shifting costs to insured patients, since insurers now dictate allowable fees.

The irony is that we are already spending more than enough to fully fund this care. But we need to stop spending it on the worthless administrative excesses of the insurers and the administrative burden they place on the system, and spend the money on patients instead.

Posted by pnhp at 10:17 AM | Permalink

Quentin Young, M.D., National coordinator, Physicians for a National Health Program
Published March 20, 2003

Chicago -- Health care in the United States has gone from the absurd to the obscene. The March 11 commentary is a shocking revelation of what seeking services has come to mean for hard-working, everyday people. It asks them, literally, to weigh the costs, to gamble with the well-being of family members, because they cannot afford health care, even after paying for health insurance.

Tens of millions of us are uninsured or poorly insured. The basic tragedy, of course, is that it does not have to be this way. We Americans already spend more than twice as much as any other nation for this dysfunctional way of providing health care. Jamie Smith contrasted her personal experience in the United States with the national health insurance system in Scotland. She describes her care there as prompt, professional, cheaper, safer, smarter and accessible.

All other industrialized democratic countries have, over the years, recognized access to health care to be a basic human right, which can best be achieved by a not-for-profit, government-administered system. When will we create a better health-care system--a single-payer national health program?

Posted by pnhp at 10:15 AM | Permalink

Public Opinion Strategies
March 13, 2003
Survey of Small, Medium and Large Businesses

When asked about the most important goal for reforming our health care
system, business leaders focus on "making health care more affordable" and
"providing basic health insurance coverage to all Americans." Of the five
health care goals tested, the most important for business leaders is "making
health care more affordable" (51%), followed by "providing basic health
insurance coverage to all Americans" (28%). The remaining three goals are
well below the top two: "maintaining the high quality of American health
care" (11%), "making sure people can select the doctor or hospital of their
choice" (6%), and "making sure the system allows the development and
adoption of new medical technologies" (2%).

http://covertheuninsuredweek.org/media/BusinessSurveyReport.pdf

Comment: Previous polls have confirmed that 98% of the general public is
concerned about making health care more affordable. This survey confirms
that affordability is also the most important concern for businesses of all
sizes.

Perhaps the most frequent argument advanced against establishing a mechanism
that contains costs is that innovation and development of new technologies
would be suppressed. This survey confirms that this is the least concern of
businesses.

If business interests had a better understanding of the single payer model,
support would increase. Of all options under consideration, the single payer
model is the only one than can effectively contain costs, and it does so by
its specific design - using a global budget. It would also meet the other
major goal supported by businesses - providing coverage for all Americans.
It would improve quality by improving access and by adoption of an
integrated information technology system. It would ensure free choice of
providers. And it would actually improve innovation and technology by
freeing up funds currently wasted on administrative excesses which would
then increase funding of the health care delivery system which utilizes the
newer technologies.

Isn't it time for business to take a much closer look at the single payer
model?

Posted by pnhp at 10:20 AM | Permalink

This is the piece that is being sent to every member of the Democratic Party Action Agenda Committee. You can use it to shape your own testimony if you wish. In any case you should put in your own or your group's perspective.

SUPPORT INCLUDING SINGLE PAYER HEALTH CARE IN THE
2003 MASSACHUSETTS DEMOCRATIC PARTY PLATFORM ACTION AGENDA

The Massachusetts Democratic Party Platform supports the creation of a single payer health care for system in Massachusetts. The support is stated as, “Our Party supports the creation of single payer health care system both in Massachusetts and in the nation in order to achieve the goal of universal health care”. This support has been included in every Massachusetts Democratic Party Platform and Action Agenda since 1993. It is even more important that it be included in the 2003 Action Agenda.

Single Payer Health Care is a unifying issue

Over the last 10 years the Republicans have gotten themselves in trouble whenever they try to attack or undermine Social Security or Medicare. There is a simple reason for this: they are universal programs. Every American resident is entitled to participate in these programs and that means that the programs enjoy the wide political support that programs that target certain populations can never enjoy. In Massachusetts, all of the programs that expanded health care coverage over the last 15 years are under attack. This is because most residents do not feel they benefit from these programs.

A single payer health care system would guarantee every resident of Massachusetts quality health care. Once established, it would enjoy broad political support that would make it very hard for special interests to undermine. Single payer health care also has the additional benefit of being the only fiscally responsible way of achieving universal health care, this has been validated by every independent study on the subject. Single payer health care provides universal health care by capturing the waste that is endemic to our current multi-payer system. Studies have determined that between 30% and 35% of our health care dollar is spent on administration and overhead. This is compared to the 10% that is the highest that is spent in any country with a unified and universal health care financing system. A single payer system would eliminate more than half of the money presently wasted and would use that money to provide quality health care to every resident of Massachusetts.

We must learn the lessons of Medicare and Social Security and create a universal single payer health care system in Massachusetts. Support for this position should be featured in the 2003 Massachusetts Democratic Party Action Agenda. This is the type of program that can help re-establish the Massachusetts Democratic Party as the party that represents the interests of all working people and their families.

Posted by pnhp at 04:08 PM | Permalink | Comments (0)

American Medical News
March 24/31, 2003
California emergency departments close after hemorrhaging money
By Markian Hawryluk

According to a new study by the California Medical Assn., California emergency departments provided $540 million in uncompensated care in fiscal year 2001, up 24% from the previous year.

... since 1990, 60 emergency departments -- nearly 15% of California's EDs -- have shut their doors.

The closures have left entire communities without emergency departments and have led to increased patient volume. Waits of more than four hours are common as physicians and nurses struggle to treat high volumes of patients, the study found.

John Whitelaw, MD, California Medical Association president:

"What we are seeing here is an astonishing growth in losses, and it shows no sign of abating. People depend on their emergency rooms to be there for them, but these losses point to a crisis of extreme proportions and underline the threat to emergency care around the state."

http://www.ama-assn.org/sci-pubs/amnews/pick_03/gvsd0324.htm

Comment: No amount of personal wealth can protect you from the threat of the deteriorating infrastructure of our emergency system. Rich people will die, along with the poor, because of the failure of our system.

Providing comprehensive coverage for everyone, funded at our current level of spending (15.2% of our GDP), with a level of efficiency available only through public administration, would ensure that our emergency system would be well funded, always there for all of us.

Posted by pnhp at 03:08 PM | Permalink | Comments (0)

The Washington Post
March 16, 2003
Health Insurance Back as Key Issue
By Ceci Connolly and Amy Goldstein

Sen. Susan Collins (R-Maine):

"My brother, a conservative small businessman, is saying maybe it's time for the government to take over health insurance. The one change I've noticed in the last few months is that businesspeople for the first time are questioning whether private health insurance can survive. It is just an extraordinary thing."

http://www.washingtonpost.com/wp-dyn/articles/A30115-2003Mar15.html

Posted by pnhp at 01:18 PM | Permalink | Comments (0)

By WILLIAM HATHAWAY
Courant Staff Writer

March 14 2003

Seven drug manufacturers have bilked patients and state drug programs of tens of millions of dollars in a complicated price-gouging scheme, the state attorney general and consumer protection commissioner charged Thursday.

"These companies raided state coffers and patients' pockets," said Attorney General Richard Blumenthal. "The victims were people paying for vitally needed medicine."

The Department of Social Services, which pays most of the $600 million Connecticut spends annually on pharmaceuticals, joined lawsuits that seek reimbursement of overcharges to state agencies and patients.

The companies allegedly inflated the costs of some drugs - chiefly those used for cancer treatments and respiratory problems - that are reimbursable under several state programs. The companies in turn sold the drugs at deep discounts to providers such as pharmacies or doctors, who were allowed to keep the difference between the reimbursement amount and the discount cost as an inducement to prescribe and sell the drugs.

In essence, the companies used state funds to help increase the market share of their drugs, the suits allege.

"It's an absolute disgrace on the part of these companies," said Consumer Protection Commissioner James T. Fleming.

The defendants in lawsuits being filed at Hartford Superior Court are Schering-Plough Corp., GlaxoSmithKline, Aventis, Dey Inc., Warrick Pharmaceuticals, Pharmacia Corp and Roxanne Pharmaceuticals, a division of Boehringer Ingelheim, which is based in Ridgefield.

Under state drug programs, the state reimburses drug manufacturers for drugs based on their average wholesale price, minus 12 percent. However, drug companies report the costs themselves to national databases and state officials have no way of corroborating them, according to Michael P. Starkowski, deputy commissioner at DSS.

As an example, a drug company might report a price of $100 for a drug that actually costs $20, state officials said. The reimbursement paid by the state would then be $88. Drug companies then offer the difference between the actual cost and the government reimbursement - a "spread" of $68 in this example - as an inducement to help market the drug.

Among the drugs "overcharged" to the state in this manner were the asthma drug Albuterol and chemotherapy drugs Zofran and Anzemet, according to officials.

"In some cases, the companies actually market the spread to doctors," Blumenthal said. "The practice is industrywide."

Four or five other states have initiated similar actions against a number of different drug manufacturers, Blumenthal said.

Bruce Lott, senior director of public affairs for the Pharmaceutical Manufacturers Association declined to comment, saying the association does not comment on business practices of individual members.

"We haven't seen the complaint," said Pamela DeMala, spokeswoman for Boehringer Ingelheim. "But Roxanne markets its products in full compliance with the law and we are confident in our business practices."

State officials said the practice hurts all consumers, but particularly those on Medicare, who pay 20 percent of the cost of some cancer treatments as a co-payment.

State officials are still trying to calculate the total amount overcharged, but initially will seek a $15 million reimbursement to the state and possibly a similar amount for consumers.

Copyright 2003, Hartford Courant

http://www.ctnow.com/news/health/hc-drugs0314.artmar14,0,571487.story?coll=hc%2Dheadlines%2Dhealth

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

The Washington Post
March 14, 2003
Editorial

Medicine for Medicare

DO NOT BE MISLED by the loud noises coming from congressional Democrats and health care activists. The Medicare modernization plan the president has finally presented to Congress, after much hemming and hawing, is not radical. It does not force anyone to leave the current system. It does not make anyone switch doctors. It adds $400 billion over the next 10 years to pay for extra drug benefits, a number far higher than some have mentioned. Unlike leaked versions of the administration's proposal, this one does not even provide full details of what the reform would look like, instead leaving Congress to fill in many of the blanks. As a result, it's difficult to say whether the proposal would produce much change.

In essence, it adds options, instead of removing them. For those who want it, traditional "fee-for-service" Medicare would be preserved more or less intact, with the addition of a prescription drug discount card as well as some catastrophic insurance. No extra payments would be required, it seems. At the same time, Medicare recipients would also be able to opt into a new program -- "enhanced Medicare" -- that would look a lot like the current federal employee health insurance plan. Those who chose this option would pay a part of the cost themselves. In return, they would get a private plan and better benefits.

Both the administration and its supporters in Congress seem to hope that over time more people (and particularly younger people, by now accustomed to a plethora of health care choices) would select this second option. If this happened, the costs of Medicare to the federal government might not come down dramatically -- private insurance isn't necessarily cheaper, particularly for the elderly -- but at least Medicare recipients would have some incentive to choose plans more suited to their specific health needs. Because they pay for more than just emergency visits to the doctor, integrated plans could also care more sensibly for the chronically ill. As a recent report by the Progressive Policy Institute points out, Medicare currently will pay if you've been hospitalized for a stroke but will not pay for the anti-hypertension drugs to prevent it. This is the kind of absurdity that a plan designed specifically to meet the needs of older people could avoid.

"Could" and "might" are the operative words here, however. The president's proposal is not a panacea but rather a set of suggestions that reflect the politics of the moment. Clearly, this president does not want to be accused of "abandoning" Medicare. On the contrary, he wants to be able to say that "Medicare will always be there, just how it's always been, if you want it that way." If Congress chooses to stick too closely to this mantra, and to keep benefits the same across the board, there will be little incentive for anyone to opt out of the current system or to contribute to the costs of his or her care. However politically difficult it appears to be, Congress must make it possible for Medicare to change with the times.

http://www.washingtonpost.com/wp-dyn/articles/A23255-2003Mar13.html

Comment: Neither of the "either-or" options behind this editorial can be good news. Either the editorial staff has failed to do its homework in understanding the fundamental principles of social insurance, or the editorial position of The Washington Post is to support a system that ensures comprehensive services for those able to afford them, but relegates lower-income beneficiaries to a program that falls short on basic health care needs. Have the editors demonstrated incompetence by failing to inform themselves adequately on the issues, or, worse, are they suggesting that personal wealth should determine whether Medicare beneficiaries should have access to all essential services?

Adding a drug discount card to the program would cost nothing, which is exactly what it is worth under this "budget-neutral" administration. And the $6000 deductible catastrophic drug coverage would benefit only the affluent. Prohibiting any other improvements in the benefit package of the traditional program would perpetuate the impaired access to care for those who are unable to afford essential services that are not currently a benefit of the program. The most immediate need is for a bona fide prescription benefit.

The Washington Post supports the FEHBP model of "enhanced Medicare," making available a private plan, with BETTER BENEFITS, by PAYING A PART OF THE COST themselves, while still prohibiting coverage of the "better benefits" in the traditional program. This would end Medicare as an egalitarian program of social insurance.

The Washington Post is supporting the shift to "consumer-directed" Medicare, not only by shifting costs to beneficiaries when offering more plan options, but also by providing "incentive to choose plans more suited to their specific health needs." But it is impossible to select a plan that will be the best choice for medical events that cannot possibly be predicted. Also, for those with chronic disorders, providing options creates all of the inequities characteristic of risk segmentation. Lower-income beneficiaries with chronic disorders would be locked into the traditional program. The Washington Post states that covering a stroke but not covering the medications that would prevent it is "the kind of absurdity that a plan designed specifically to meet the needs of older people could avoid." Yet The Washington Post has endorsed precisely this type of absurdity.

Is this editorial incompetence, or is it support for the concept that there is a "lower class" that is not entitled to all essential health care? Perhaps The Washington Post does not want them to have their "cake," but, rather, "Let them have strokes."

Posted by pnhp at 12:10 PM | Permalink | Comments (0)

By REKHA BASU
Register Columnist
03/12/2003
The Des Moines Register
http://www.dmregister.com/opinion/stories/c5917686/20705781.html

My teen-age son has a thing for Ultimate Frisbee. Such a thing that he kept on playing last week even after hurtling into a fence, splitting open his knee and getting an egg-size bump on his cheek. Later that evening, we sat in the hospital emergency room as one doctor stitched him up and another checked for a concussion.

It's not pleasant, but it's life: People are active. Sports come with risks. You just brace yourself for the occasional accident and feel lucky if the worst result is a superficial scar and a $75 hospital co-pay.

But it's not that simple for everyone. The same minor accident that costs one family an evening can force another to fall behind on rent or car insurance.

Ask Anna Dianas of Des Moines. Her $7-an-hour job for a non-profit group provided no health insurance. Her husband, who does seasonal construction work, gets none either. They couldn't afford to buy it and don't qualify for any government program. So when her husband split his head open in a soccer collision, a hospital visit similar to ours set a struggling family back $500.

"We barely make it," Dianas sighed. She racked up another $3,000 in hospital bills after she got chest pains and an EKG at a free clinic was abnormal.

Dianas was one of the people showcased Monday by the organizers of Cover the Uninsured Week, as panelists brainstormed about the health-care crisis and Lt. Gov. Sally Pederson read a proclamation urging solutions.

Dianas will soon get coverage thanks to a job change. But that still leaves more than 230,000 Iowans without insurance. Eighty-six percent of them work. They live with untreated illnesses, turn up at clinics created for the poor, rely on the good graces of doctors to slip them free samples of medicine. They live sicker and die younger, says Families USA, a consumer organization.

People variously lay the blame on: premiums that shot up 30 percent in three years; rising co-pays and deductibles; struggling small businesses unable to cover their workers; costly medical technology and drugs; poor federal reimbursement rates for Medicaid and Medicare; and an aging population using more services. You could also look further, to the loss of manufacturing jobs with union protection that ensured health benefits. In America, 1.4 million people lost their coverage in 2001; 41 million are uninsured.

For all its wealth, ours is the only industrialized country without a national health-care program, says Senator Tom Harkin. "We have the best hospitals, the best personnel and yet we can't cover people."

Working people often are caught in a Catch-22 because their jobs don't come with benefits, but they are paid too much even for their kids to get government help. That's Lorri Swigart's problem. She's a full-time property manager earning around $2,000 a month. Her income puts her 16-year son, who has juvenile diabetes, above the guidelines for Hawk-I, the state's medical program for low-income children. His insulin-related expenses alone run $150 to $175 per month. She takes heart medicines.

They lost their coverage in January after she got divorced, and when she finally found an insurer that would cover them, it cost too much. "You just put things off for as long as you can," she said. "You don't go to the dentist, or you have a tooth pulled vs. a root canal or a cap. I just went to the dentist. I want to save my tooth but it's $1,500 vs. $75."

If something catastrophic led one of them to be hospitalized, she says, she'd have to file for bankruptcy. Medical bills are in fact a leading cause of bankruptcy.

Chances are that someone you know has no medical coverage. My friend Kim Davenport, who lives in Dallas County, works as a waitress and discontinued her employer-supported plan when the premium shot up to $700 a month. Her husband is self-employed, so there's no coverage for them or their two teenage daughters.

"I'm just hoping nothing happens, that's all," she said.

Poignant as these stories are, they're not presented for your pity, but your outrage. Something is terribly wrong when working Americans have to worry about a sports injury delaying the rent.

There is a solution, but no political will for it: a nationalized health-care system like Canada's, which spends less per person and covers everyone (see Andie Dominick's Feb. 14 Register essay). Canadians have a higher life expectancy, and their overall taxes are not higher.

President Bush decried such a system in his State of Union speech, and insurance-industry advocates are fond of spreading horror stories about waits for service and lack of choice in doctors. But there's not much choice in health care for many Americans now.

The good news is that political will can be forced. If you doubted that, just look at how Des Moines schools capitulated to a public outcry last week within 24 hours of floating a proposal to merge 40 high school sports teams into eight. Imagine if such energy were channeled into demands for a better health-care system.

Posted by pnhp at 03:25 PM | Permalink | Comments (0)

The Des Moines Register
March 12, 2003
Editorial: Work on worry No. 1
By Register Editorial Board

Pick your biggest personal worry: losing your job, not being able to pay the mortgage, losing money in the stock market, becoming a victim of a terrorist attack.

All those concerns are beaten out by people worrying about the cost - and future - of health care, according to a recent survey conducted for the Kaiser Family Foundation.

They should worry.

* America spends more on health care than any other nation, yet this country ranks poorly on life expectancy, infant mortality and immunization rates. An expensive, hodgepodge system isn't getting the job done.

* A 2000 survey by the World Health Organization ranked the U.S. health-care system 37th overall. In the "fairness" category, this country came in 54th, right in line with Fiji.

* More than 40 million Americans are uninsured.

* Soaring health-care costs contribute to everything from teacher layoffs to bankruptcies to the federal deficits. They hurt the economy and diminish quality of life.

Americans should be concerned.

That concern should spur people to demand real change. Instead, those in Washington remain focused on patching up individual pieces of the hodgepodge system.

The latest example is Medicare. It stands to consume one-fourth of the federal budget by 2030, yet seniors expect a costly new prescription-drug benefit to be added. How should Medicare be reformed?

That's the wrong question.

The right question is: How can the U.S. health-care system be reformed in its entirety? The American people are being duped if they continue to allow politicians to narrow the larger debate about health care down to plugging only one hole in a ship that's full of holes. The debate can't focus just on Medicare, or just on Medicaid, or just on the uninsured, or just on rising costs to employers and their employees. They're all facets of the same problem.

All of America frets about health care, according to the Kaiser survey. It's time to get serious about devising a system that works for all of America. That would be one that covers everyone and slows the increase in costs.

http://www.dmregister.com/opinion/stories/c2125555/20709539.html

Posted by pnhp at 01:40 PM | Permalink | Comments (0)

Posted on Thu, Mar. 13, 2003
Too many fall through the cracks of inadequate insurance programs.
By Gene Bishop
http://www.philly.com/mld/inquirer/news/opinion/local2/5378484.htm
The Philadelphia Enquirer

More than 18,000 young adults died last year in a major epidemic in the United States that managed to escape the headlines.

Those 18,000 - six times the number who were killed in the attacks on the World Trade Center - died, according to an Institute of Medicine report, because they lacked health insurance. No alert has been issued to help those who daily live in terror of becoming sick and being unable to pay.

There is the college graduate working as a waiter while trying to succeed as an artist. At work he has a seizure and is rushed to a hospital. He is discharged two days later with a prescription for medication and instructions to make an appointment to see a neurologist.

Although emergency medical assistance (Medicaid) may pay for the hospitalization, he is not eligible for Medicaid once outside the hospital because he is able to work. An appointment with a neurologist in Philadelphia could cost $250 or more, in addition to the cost of medications, blood work, and further diagnostic testing. He doesn't have the money.

His is hardly an isolated story. As a physician who cares about access to health care, I consider myself knowledgeable about health-system problems. But having spent the last 18 months working with the Pennsylvania Health Law Project, a statewide legal services organization, I am overwhelmed. I am filled with anger as I hear story after story about Pennsylvanians who are struggling to take care of themselves or their families, but are unable to pay for doctors, hospitals or medicine.

The Health Law Project's toll-free helpline for low-income Pennsylvanians having difficulty accessing or using the health system documents a system that is falling apart. There is the call from the social worker at a low-cost clinic. Her client has been diagnosed with a brain tumor and needs radiation therapy. The woman's income is too high for Medicaid, and three hospitals have refused to register her for a specialist appointment because she is uninsured.

Or the man with diabetes, employed and uninsured, who sees a physician at a low-cost community health center where he pays for his medicines and physician visits. When his doctor tells him he needs an eye specialist and possible laser treatments to prevent blindness from diabetes, he doesn't have the money. He and his lawyer make numerous phone calls trying to obtain affordable care. One hospital says it has "used up all the charity care for the year." He becomes overwhelmed by the obstacles in his path, and the possibility of large debt. He takes his chances with his sight.

Few uninsured people come to my practice, but the underinsured are plentiful. Every day, people tell me they aren't taking their medications because they can't afford them. Insurance companies have shifted the cost of care to consumers.

Low-cost coverage now available to a limited number of Pennsylvanians is also inadequate. Special Care insurance, sold by Independence Blue Cross, allows four physician visits per year and doesn't cover medications. One serious illness or accident can use up those visits. Adult Basic Coverage - funded by the tobacco settlement and run across the state by private insurers - began in July and filled its 48,000 capacity almost immediately. Even without coverage for prescriptions, mental health or drug and alcohol treatment, it has a long waiting list.

During this national "Covering the Uninsured Week," it is time to focus again on providing universal coverage for all Americans. We already have more than enough resources in our health-care system to provide comprehensive health-care benefits to all. A national health insurance program, which would eliminate the high overhead and profits of insurance companies, offers the promise of adequate health care for all Americans.

U.S. Rep. John Conyers (D., Mich.) recently introduced a resolution calling for a national health program. On the Web, there is a national physicians' proposal backing such a program (www.physiciansproposal.org).

As a physician in such a system, I could treat patients without checking on the rules, medication lists, or billing requirements of 10 to 20 insurers. As a patient in such a system, you or I could visit any doctor or hospital we choose, rather than the ones chosen for us by our employer, our insurer or our income. Only national health insurance allows us to expand coverage without expanding costs.

A patchwork quilt of inadequate insurance programs, each with its own set of rules and administrative costs, is not the answer. It is time to trade this torn quilt for a well-sewn blanket of universal coverage. It is time to save 18,000 lives - and save ourselves.

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

Seattle Post-Intelligencer
March 12, 2003
National solution best for health care
By Mary O. McWilliams

Here, in the midst of Cover the Uninsured Week, it is important that this be said: All Americans should be covered by health insurance.

To that end, I offer the following principles to guide the debate. These ideas center on the values of individual responsibility, collective accountability and equality.

* Coverage for all is a national public policy matter.

* We should focus on adding to the coverage that exists today.

* We must acknowledge that solutions will have a cost.

* We need a basic set of health benefits as the floor.

* This is a collective responsibility.

* Government-sponsored programs must be adequately funded.

* We must improve the current system.

* Consumers must have a direct relationship with the cost of care.

It is to be hoped that these concepts will further spark a meaningful debate, which must continue in earnest beyond the focus of this week.

Mary O. McWilliams is president of Regence BlueShield.

http://seattlepi.nwsource.com/opinion/112031_regence12.shtml

Comment: During Cover the Uninsured Week, there is a unified voice stating clearly that everyone should be covered by health insurance. Listening to the various interests, it almost sounds like we finally agree that we must have a universal, egalitarian system. But then there are always the details.

Ms. McWilliams believes in a national solution, as long as that solution protects her industry, funds it more generously, and allows it to shift the burden of actually funding health care to the individual patients, to "encourage cost- and quality-conscious purchasing." What will her position be if it is decided to reduce expensive administrative excesses by eliminating middleman health plans and adopting a single public payer?

Cover the Uninsured Week should not only end with a resolve to cover everyone, but it should also end with a resolve to put the interests of patients above all others. Without such a resolve we will flounder and founder.

Posted by pnhp at 04:54 PM | Permalink | Comments (0)

March 12, 2003
BY CINDY RICHARDS
The Chicago Sun-Times

For 30 years, Rebecca Sawyer-Spoon and her husband, Joe, lived the American dream. They ran a small business, paid their taxes and prospered. Now, she's a statistic.

Sawyer-Spoon is one of the 41 million Americans without health insurance, even though she works full time and brings home a comfortable, middle-class living.

She was one of several victims of the Great American Health Debacle to speak during a moving town meeting Monday at the Harold Washington Library, one of a score of events being staged this week in Chicago--and hundreds being staged across the country--as part of ''Cover the Uninsured Week.'' The week is supposed to raise awareness of the growing number of working Americans who either can't get health insurance or can't afford the insurance they could get. The message, however, is getting lost amid the media scramble to cover the war on terror.

''Why isn't health care considered protection by the government? We feel so much more terrorized in our daily lives by our lack of access to health care than we do by foreign terrorist attacks,'' said Sawyer-Spoon, a resident of rural Downstate Charleston.

The Spoons had health insurance until their provider went out of business. She had been diagnosed with a mild case of asthma, and her husband was diagnosed with high cholesterol. Their pre-existing conditions precluded them from finding other insurance.

Now, when she goes to the doctor to renew her asthma prescription, Sawyer-Spoon said, ''I won't let him touch me.'' What if he found some other health problem?

She could get the necessary treatment and then file bankruptcy to avoid paying for it. That's what doctors suggested Chicagoan Frances Camberis do when she was diagnosed with a fibroid tumor and spent four uninsured days in the hospital. She hadn't been able to get health insurance, Camberis said, ''because I'm fat.'' The bill for that hospital stay was $28,000. She liquidated her retirement plan to pay it.

Not only do the uninsured wait to get necessary treatment, ensuring that they will need more costly care, they pay more for the care they get. A study released last week by the Service Employees International Union shows people who pay medical bills themselves are charged more for the same services. Large insurance companies, large employers and the federal government (which pays for 60 percent of health care through Medicare and Medicaid) use their buying power to negotiate better rates from doctors and hospitals.

All in all, it was a rather depressing two hours. Having been a statistic in the past--my union's health insurer collected our premiums but never paid our providers and ended up in receivership, leaving hundreds of us uninsured and hounded by bill collectors--this is a subject near and dear to my heart. During the time I was uninsured, a nasty cold turned into pneumonia, which triggered asthma. I doubt I will ever be able to buy an individual health insurance policy again.

While Monday's meeting was long on emotion, it was woefully short on solutions. Sen. Dick Durbin (D-Ill.) opened the session by lamenting the lack of leadership on this issue in Washington, then headed off to catch a plane before explaining why he hasn't stepped up to the plate. Rep. Rahm Emmanuel (D-Ill.), who worked in the Clinton White House the last time health care topped America's political agenda, will introduce a bill soon that would expand coverage for lower-income Americans.

But this is no longer a lower- income problem. It is a mainstream problem. The flagging economy is sapping employers' ability to offer health insurance, the high cost of technology and malpractice insurance is raising the cost of health care, and the risk aversion of insurers is leaving more and more Americans unable to get coverage at any cost. Even those of us who have health insurance today have no guarantee we'll still have it tomorrow should a layoff, the death of an insurance-providing spouse or even a costly illness mean the end of our insurance benefits.

This is the terror President Bush should be fighting.

Posted by pnhp at 10:31 AM | Permalink | Comments (0)

By Jamie Smith. Jamie Smith lives in Pearl River, N.Y

March 11, 2003
Chicago Tribune

I don't have health insurance.

Unlike many of the 40 million Americans without health insurance, I could get coverage fairly easily. I am a speech pathologist by training, and it would not be hard for me to get a job with health benefits. But I have three small children, and when the oldest was a baby I decided to do what it took to stay home. What it takes is living without good health insurance.

We live, the five of us, on my husband's modest income. We live simply, in a small apartment. We have no car and we eat a lot of lentils. Mostly, we prefer it that way. I like lentils. The problem is health care.

We practice preventive medicine as far as possible. I breastfeed; I childproof; I serve my family nutritious food; I am a hand-washing fanatic. But breastfed babies can still get ear infections. Toddlers can split their heads open on a worrisome array of innocuous-looking objects. And 4-year-olds can still get pneumonia, vitamin C and hand-washing notwithstanding.

We have almost always had some sort of coverage--cheap policies with high deductibles from companies you never heard of. But we have never gotten a dollar back from one of these policies. We buy them just in case--just in case somebody gets cancer, or falls out of a window, or gets hit by an uninsured driver. When we received the notice that the premium for our last policy was rising by 35 percent, I went rampaging around my apartment. "I could have stood on the roof and flung the money into the wind for all the good this policy has done me, and now they want more money for the useless thing?" And then I paid the bill.

Just in case.

I follow the newspaper coverage of the health-care crisis. The articles are all too familiar. "Doctors raise charges for patients without insurance," the paper tells me, as I observe grimly that I have been charged $140 for a 10-minute well-child exam. An insurance company has the clout to announce that it will pay only a third of that amount; the uninsured patient who tries that strategy will quickly find himself in the hands of a collection agency.

"Premiums rising," the headlines say. Don't I know it.

I used to think that was just the way things were--until we moved to Scotland for two years. While the National Health Service has many flaws, it was a revelation to see how well universal coverage could work. When my oldest son fell and needed stitches, I took him to our local children's hospital. We were treated promptly and professionally; he has a tiny white scar and pleasant memories of the hospital. We chose to have our second child while we were living there, and I was struck again and again by the wisdom of the British system of perinatal care: cheaper, safer, smarter, accessible to any pregnant woman regardless of the vagaries of her employer's benefits plan.

When we returned to the U.S. I found myself questioning the third-party payer system. Why do we pay so much money to insurers, who make a profit based on how little of it is passed along to the people who provide the services?

What if we cut out the middleman? Why have for-profit entities been afforded so much decision-making power?

Back in the U.S. my second son fell into an end table on a Saturday afternoon.

As I surveyed the gash on his forehead, I found myself wondering how much an emergency room visit would cost and how big his scar would be if we didn't go--hating myself for making the calculation, making it anyway. A friend had been billed $1,000 to repair a comparable injury. We stayed home. With shaking hands and butterfly bandages I brought the edges of the cut together. But I am no doctor. His scar is not conspicuous but it is present. And every time I see it I feel guilty.

I know I am far from alone in my frustration. Every time health insurance comes up in conversation, more questions surface about the long-term cost of the third-party payer system. How many children lose out on having a sibling because of the cost of maternity coverage? How many people abandon the dream of owning a business because of the cost of providing health coverage for a family? How many retirement-age employees slog on at work to provide health insurance for a spouse?

In the busy pediatric clinic where I worked before my first child was born, almost all the receptionists who became pregnant returned to work after their maternity leaves. The pay was meager (especially given the cost of child care) but the benefits were good; they needed the insurance.

After his second post-doctoral research position, my husband decided to switch career directions and get off the academic track. I was relieved at the prospect of having health benefits, but I found myself with more questions.

Would it be unethical to participate in a system which is so fundamentally unjust? Would I really have the gumption to decline health benefits on ethical grounds? I didn't need to worry; another headline intervened--"Employers cutting dependent coverage." My husband's company offers no benefits to dependents. I could buy insurance if I paid 15 percent of his monthly take-home pay to do so.

I declined. You can buy a lot of lentils with that amount of money. But the questions remain: Is it right to participate in a profoundly unjust system?

How many people have to demand other options before other options become available?

I'm still waiting for answers.

Posted by pnhp at 02:11 PM | Permalink | Comments (0)

United States Senate Special Committee on Aging
March 10, 2003
Testimony of Karen Davis, President, The Commonwealth Fund

Time for Change: The Hidden Cost of a Fragmented Health Insurance System

Executive Summary

We have entered the 21st century encumbered by a health system that is not up to the challenge of ensuring a healthy and productive nation. Set in motion over 50 years ago, the system is costly, complex, and confusing. Most important, it is failing to achieve the twin objectives of health insurance: to ensure that people have access to needed medical care and to protect them from the financial burdens of costly medical bills.

There are five types of costs inflicted by our fragmented health insurance system:

* Costs of a growing number of uninsured

# 41 million Americans in 2001 fell through the cracks of the American health care system because they were not lucky enough to be covered by employer-based coverage, Medicare, Medicaid, or the Children's Health Insurance Plan

* Health and economic consequences of gaps in health insurance coverage

# 18,000 deaths of adults ages 25 to 64 occur each year as a result of the absence of health insurance coverage - making it the sixth-leading cause of death in this age group, ahead of HIV/AIDS or diabetes

* Cost-shifting that occurs in a fragmented financing system, especially as health care costs accelerate

# 70 million American workers are covered by their own employer; 20 million by a family member's or previous employer; 30 million are not covered by an employer

# Our "pass the buck" system of health insurance perpetually shifts costs from one employer to another, employers to workers, federal government to state governments and back, and to safety-net hospitals serving the uninsured

# Far more energy goes into shifting costs than enhancing efficiency or quality of health care; insurance companies are profitable by attracting favorable risks, not through innovative incentives to improve quality and efficiency

* Costs of churning in health insurance coverage, as people's economic and personal circumstances change

# Churning results in frequent gaps in insurance. Sixty-two million - one of four - were uninsured during 2000; 75 million were uninsured in 2000 and 2001. These people were at high risk of not getting care when needed and facing unaffordable medical bills when care could not be postponed.

# The U.S. spent $111 billion in 2002 on private insurance and government administrative costs - not including administrative costs incurred by hospitals and other health care providers or by individuals as they enroll, disenroll, and re-enroll and change insurance coverage and plans.

* Costs of complexity from a pluralistic system of health insurance without an integrating framework and consensus on basic principles

# Cost of large numbers of individuals eligible for but not enrolled in public programs

# Cost of lost productivity, health, anxiety, sick days, and valuable time of uninsured patients spent seeking care

# Cost of resources wasted on administration - jobs underwriting, screening, and verifying eligibility; new administrative apparatuses to cover narrow target groups of eligible individuals; costs of enrolling and disenrolling for public and private insurers and for individuals

# Costs of inefficient and low-quality care - high costs in emergency rooms for preventable conditions and hospitalizations; costs of differing standards of care depending on insurance status

# The U.S. spends twice as much per capita on health care as other industrialized OECD nations and is the only one to fail to cover everyone

There has to be a better way:

* Automatic and affordable coverage for all

(Truncated. See "Comment" for the solution suggested.)

http://www.cmwf.org/programs/insurance/davis_senatecommitteetestimony_622.pdf

Comment: Karen Davis has provided the rationale for ending our fragmented health insurance system. The obvious conclusion is that we need a single, publicly-funded and publicly-administered insurance program. But here is the solution that Karen Davis offers:

"We have built an incredibly complex, costly, and confusing health insurance system. We need a single guiding framework for coverage. It can include multiple sources of financing, multiple choices of public and private coverage, and multiple benefit packages, but it needs to be integrated within a single framework. Certainly, we should have a system that preserves innovation, flexibility, and choice, but some standardization will be required to cut through the maze of complexity in our current system. Reaching consensus on the parameters of choice versus standardization is an important part of public debate on this issue."

It is astounding to see the efforts that are being made to avoid a program of social insurance but instead to build on our current fragmented system. To present compelling arguments on why the fragmented system does not and cannot work, and then to suggest that we build on it, defies all logic.

Posted by pnhp at 12:45 PM | Permalink | Comments (0)

Posted on Thu, Jan. 23, 2003

By Molly Ivins Creators Syndicate

Bet you if I had a nickel for every time someone has started an article or a speech in the past five years by saying, "The nation's health care system is facing a crisis," or, "Our health care system is falling apart," I would be a rich woman today.

I suppose I could come up with some dramatic metaphor for the crumbling, tottering, greed-rotted structure, but hey, why don't you check out your health insurance premiums and see how you're doing? Up by 12 percent, 22 percent, 40 percent?

Larger premiums, higher deductibles, increased payments for prescription drugs? Employer dropping your coverage? Are we having fun yet?

Our money-corrupted political system isn't about to address the systemic problems. I think it's almost self-evident that a single-payer system is the best answer to all the problems, but since we have to deal with political reality, let's shelve that plan for now.

The last time anyone tried to do anything about the whole system -- Hillary Clinton with a not-very-good plan back in '93 -- she was shouted down by $10 million in insurance company ads, still the record for the most money spent ever to defeat a single bill.

Now we've got 41.2 million Americans with no health insurance -- 14.6 percent of us -- which ends up costing us more than it would to pay for their insurance. We pay the world's highest health care taxes. Our government spends $2,604 per capita, the highest of any nation, including those with national health insurance, even though only a quarter of our population is covered by government insurance.

We spend 13 percent of our GDP on health care, the highest in the world. The average in the European Union and in other developed countries is 8 percent. According to the Organization for Economic Cooperation and Development, we spend a total of $4,600 per capita for health care, more than twice the average of other countries.

We ain't getting much bang for our buck, either. Forget the "we have the finest health care in the world" claims. In both life expectancy and infant mortality, we're below the median for developed countries.

If you stand back and look at the fiscal crisis in the states and cities, you will see that almost all of it is driven by health care costs. Naturally, the strapped states and cities can't think of anything to do except start knocking people off Medicaid and the Children's Health Insurance Program (CHIP). That just means they wait and get sicker before they finally end up in the emergency rooms, costing us all more money in the long run.

Sometimes the sheer stupidity of our choices is amazing.

One chunk of this insanely complicated system that the politicians are now preparing to tackle is medical malpractice costs. "Med-mal," as it is known in the trade, is currently the subject of a particularly fruitless hissing match between Republicans and Democrats over whether the trial lawyers or the insurance companies are to blame for astronomical increases in premiums. This is complicated by the fact that trial lawyers give money to Democrats and insurance companies give money to Republicans.

We've all heard of ridiculous lawsuits by trial lawyers looking for a buck. The insurance companies have well-funded campaigns to publicize idiotic suits -- they do not publicize it when the suits get thrown out of court. Of course, we've all heard of ridiculous medical mistakes as well.

It has never been clear to me why the American Medical Association goes along with blaming trial lawyers rather than insurance companies when their malpractice rates skyrocket. The fact is that malpractice is committed by a tiny percentage of doctors -- 5 percent, according to Public Citizen -- and the AMA could save itself and everyone else a lot of trouble by getting rid of them.

In Texas, we've had zero doctor's licenses revoked because of medical errors since 1997, despite 6,038 medical malpractice claims reported to the state, including 150 times that surgeons operated on the wrong part of the body.

Of course, trial lawyers do drive at least a part of med-mal costs, but if you examine the competing claims (under the Bush administration, you have to be wary of government data because it increasingly uses only insurance industry figures), the insurance industry is the primary villain. (If this were a lawsuit, the trial lawyers would figure out how much blame to assign to each of the parties to the last decimal point.)

According to The Wall Street Journal, the insurance industry folks are jacking up prices not just because their investments in the stock market have fallen dramatically but also because they fouled up their pricing practices in the early '90s. They seriously underpriced med-mal and are now trying to recoup, and for this they blame the trial lawyers.

California is an interesting case in point. The state passed a tort reform bill, limiting what one can recover in a lawsuit, in 1975 and waited expectantly for insurance premiums to go down. They nearly tripled in the next 12 years, finally leveling off in the early '90s. And, amazingly enough, California just happened to have passed strict insurance regulations in 1988.

Molly Ivins writes for Creators Syndicate. 5777 W. Century Blvd., Suite 700, Los Angeles, CA 90045

Posted by pnhp at 09:42 AM | Permalink | Comments (0)

Economic and Social Research Institute February 2003 Issues in Coverage Expansion Design

Coping with Risk Segmentation: Challenges and Policy Options by Elliot K. Wicks, Ph. D.

A factor that complicates almost all proposals to extend health insurance coverage is how to cope with risk segmentation in the small-group and individual insurance markets. Experience in these markets shows that if market forces are left to operate unfettered, people seeking private health insurance will be segregated into small risk pools that reflect their expected risk of incurring medical expenses and charged premiums accordingly. Premiums will vary widely across the spectrum of expected risk, and risk will not be widely shared. These are problems that generally do not plague large employers, because they are large enough to form their own risk pools and self-insure; that is, costs are sufficiently spread among higher-risk and lower-risk employees within the group. So the discussion that follows applies to health insurance for small employers and individuals buying coverage on their own.

Risk segmentation and the consequent wide variation in premiums create at least two kinds of problems. First, some high-risk people are not able to afford coverage. Second, the wide premium spread requires some people to pay much more than others for identical coverage, which many would consider inequitable.

Alternative Ways to Deal with Risk Selection

Prevent Risk Selection

Approach 1: Require insurers, in setting premiums, to community rate everyone.

Approach 2: Require everyone in some subset of the population who purchases coverage to buy from a common source and have each insurer base premiums on the experience of all its enrollees in the pool - for example, require all small employers to buy from a purchasing cooperative or insurance exchange.

Approach 3: Instead of charging people premiums, use public financing, as with the Medicaid and Medicare systems.

Approach 4: Single payer without health plans that accept any risk.

A single-payer system that did not put health plans at risk - as with fee-for-service Medicare - would solve both sides of the risk segmentation problem. Enrollees would not pay premiums, and thus there would be no difference in cost associated with risk differences. And insurers would not bear risk - they would just administer the system - and thus there would be no reason to compensate them for differences in the risk of the people they enroll. There would be no risk segmentation because there would be only one insurer - government.

Allow but Offset Risk Selection

Approach 1: Allow wide (though perhaps not unlimited) variation of premium based on price, but provide subsidies to help high-risk enrollees pay the high price they will face.

Approach 2: Make risk selection unprofitable by having a very good risk-adjustment process.

http://www.esresearch.org/newsletter/february03/risk_segmentation.pdf

Comment: This report describes the policy implications of various approaches to segmenting risk. It is worthwhile reading this nine page report because you will understand the problems that arise with each approach. Understanding risk segmentation makes it clear why it is so difficult, or, actually impossible, to ensure that everyone has equitable, affordable health care coverage. But the exception is the single payer approach which is unique because there would be no risk segmentation since there would be only one insurer - the government.

Why do we waste so much effort and expense on playing the risk segmentation game, perpetuating inevitable inequities, when we can save time and money and establish equity by dumping the health plans and establishing a single payer system? Do we have an aversion to logical solutions?

Posted by pnhp at 09:40 AM | Permalink | Comments (0)

Although I had stated that I would limit postings on this list to health policy issues, because of the volume of responses received, I am unable to respond individually to your comments on my "weak apology" for the anti-war poetry. Thus this message.

Simply stated, my faith has been restored.

Although somewhat narrowly focused, I believe that the comment on a sign at peace demonstrations in Los Angeles, graciously forwarded to us by Anne Marie Staas Niedorf, expresses the sentiment and priorities of most of us:

SADDAM DIDN'T CLOSE MY HEALTH CLINIC

Posted by pnhp at 09:38 AM | Permalink | Comments (0)

The Access Project, with other organizations February, 2003

The Consequences of Medical Debt

Summary of key findings:

* Having health insurance does not always protect individuals from out-of-pocket medical bills they cannot afford to pay. In our survey of low-income individuals in three communities, respondents with and without insurance were struggling with comparable levels of medical debt.

* Confusing and multiple bills, and the challenge of understanding what is owed and to whom, add to the problem.

* Provider practices - requiring cash payment upfront, flatly refusing care or suggesting people use other sources of care - made it harder for many respondents with medical debt to access care with any regularity. Patients often responded to these practices by not seeking care or filling prescriptions, or otherwise not complying with treatment regimens.

* Health care providers seem to be adopting more aggressive collection procedures, including turning over their accounts to collection agencies 30 to 60 days after a missed payment (instead of a more customary 150 to 210 days) and encouraging patients to pay off their medical bills with credit cards, a practice that burdens patients with not only large debts, but high interest payments as well.

* Many of the individuals we interviewed wanted to pay off their debt and had tried to negotiate payment plans, but found the terms of the plan very difficult to maintain given limited incomes and apparently inflexible hospital collection practices.

* Few respondents, in spite of very low incomes, were able to secure public assistance to defray the cost of their medical care. Many turned to family and friends for help, suggesting that communities may help relieve the burden of medical debt, but also share in it.

* Like other forms of debt, medical debt can have substantial financial consequences, including serious credit problems and, in extreme cases, personal bankruptcy. However, unlike other forms of debt, medical debt is often involuntary, the result of an event over which one has little or no control.

* Bankruptcy may offer a means to relief from medical debt and from the harassment of collection agencies and its attendant stress. This is particularly the case for the uninsured - people who are likely to have relatively fewer resources and be less able to make regular payments on their debt.

* Medical debt made it harder for respondents to achieve self-sufficiency; they were hindered in their ability to get a bank loan and other lines of credit, to save money, or to pay for basic goods and services.

* The effects of medical debt can be compounded if a health problem leaves a person unable to return to work. Because of the debt, people may be deterred from seeking the care needed to allow them to work. Job seeking may also be hindered by the fear of wage garnishments.

* Respondents told us that medical debt caused significant stress, anxiety and feelings of hopelessness. Medical debt can also be a source of embarrassment and shame, and many respondents were frustrated and angry that they were being financially punished for a medical event over which they had little control.

Health care is a business unlike most others. The customers are, by definition, in a vulnerable position by virtue of the medical problem for which they seek services. The providers of these services differ from sellers in most other markets because their product is essential and often life saving, and is governed by ethical responsibilities that exceed those that apply in typical commercial transactions. Purchases are often sudden and unplanned and, particularly for people without health insurance, may bring large financial burdens that are involuntary in the sense that they are not the result of a traditional consumer choice.

http://www.accessproject.org/downloads/med_consequences.pdf

Comment: Warning: this report is difficult to read. It is not a report of technical complexity. Rather it is a report that has a Dickensian quality, including the Tiny Tims whose suffering is compounded by medical debt, and the institutional and individual provider Scrooges with their passive automaticity when faced with the "need" to collect unpaid debts. The report is punctuated with quotations. If you cry easily, this may make you do so.

We are spending $1.66 trillion on health care this year. Our existing policies ensure that our administrative excesses will always be fully funded for the benefit of the insurers. But our policies are not designed to prevent medical debt for vulnerable patients. Yet only a very small portion of funds directed to the wasteful administrative excesses would be more than adequate to cover all medical debt. It is so tragic and so needless.

Let's change our policies. Let's reduce the waste by changing to an administratively efficient, public insurance program, and use the savings to provide everyone comprehensive coverage. Medical debt then could be relegated to the Dickensian novels where it belongs.

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

What is California HealthCare Foundation's true mission?
By Don McCanne

Following is a description of the California HealthCare Foundation from their own website:

"The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California's health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care.

"CHCF's work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions.

"CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems."

And California HealthCare Foundation's stated mission:

"Mission statement: to expand access to affordable, quality health care for underserved individuals and communities and to promote fundamental improvements in the health status of the people of California."

Understanding the origin of California HealthCare Foundation (CHCF) is important. During the decades that Blue Cross of California was a non-profit entity, it received favorable tax treatment not available to for-profit insurers. When Blue Cross of California converted to a for-profit entity, becoming a subsidiary of WellPoint, it was decided that the accrued value of the tax subsidy should not be granted gratis to the new shareholders of WellPoint, but should utilized for the benefit of Californians since this vested interest rightfully belonged to them. It was decided that this could be accomplished by establishing the California HealthCare Foundation and the California Endowment. The funds would then be used to improve the health care system in California, benefiting the underserved, and, in fact, benefiting all Californians by "improving the delivery and financing systems."

Mark D. Smith, MD, MPH, President and Chief Executive Officer of California HealthCare Foundation, has infused foundation funds into research and reports on health plans, managed care, insurance markets, MediCal and other aspects of our current system. But he has often expressed his view that a single, universal health insurance program is not an option for reform. In spite of the California Health Care Options Project study that demonstrated that single payer reform could provide affordable, comprehensive coverage for all Californians (a goal of CHCF), he seems to continue to exclude that option from CHCF activities.

Yesterday we saw an interesting example of this apparent bias. The Kaiser Daily Health Policy Report sends out summaries of important policy issues, published by The Advisory Board Company. One item yesterday included reference to a New York Times article on employers' concerns about health care costs, along with reference to the USA Today editorial debate on two views of controlling health care costs. It ended with my comment that we need to throw out the wasteful, ineffective health plans and spend the money on patients instead.

The items of national interest are often repeated in their entirety in California Healthline, a similar publication of the California HealthCare foundation, also published by The Advisory Board Company. The article above was no exception except for one remarkable difference. The New York Times segment was carried, but the USA Today segment on controlling costs by replacing health plans with a public program was deleted and another USA Today story on reducing costs by exercising and eating well was substituted. Is it not unreasonable to ask what happened? Why was a statement highly unfavorable for health insurers such as Blue Cross deleted?

The health care crisis in California, and, indeed, in the nation has reached proportions such that reform is mandated. This is the time to be examining all options for reform. An informed state and national discourse are essential. The California HealthCare Foundation should be front and center as a resource on policy issues. And since they are utilizing funds that originated from California taxpayers, they have an ethical obligation to be certain that their process is as open and unbiased as possible.

It is reasonable to ask a few questions.

* Does Blue Cross/WellPoint still exert any control over this process that has deliberately excluded options that would remove Blue Cross as a player in the health care system?

* Do members of the board of directors have any conflicts of interest that might cause them to fail in their ethical obligation to support the interests of Californians and their health care system?

* Does Mark Smith have either an ideological bias, or a vested interest in California health plans, especially Blue Cross, that might disqualify him from administering ethically the California HealthCare Foundation in the interests of all Californians?

* Why did The Advisory Board Company take the unusual step of changing a portion of this one article for publication in California Healthline?

* What is California HealthCare Foundation's true mission?

These and other questions I believe are quite reasonable. I don't have the answers. Perhaps those in the media receiving this message may want to try to discover the answers. If you have friends interested in investigative reporting, you may want to forward this message to them.

The rest of us must intensify our efforts to demand fairness and openness in the process. We must be sure that the reform we end up with will be in the best interests of all patients.

About CHCF: http://www.chcf.org/aboutchcf/

Kaiser Daily Health Policy Report on the New York Times article on employers' health care costs, and on the USA Today debate on managing costs (requires registration): http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=16431&dr_c at=3

California Healthline on the New York Times article on employers' health care costs, and on a substitute USA Today article on reducing costs by exercising and eating well (requires registration, and limited to California residents): http://www.californiahealthline.org/members/basecontent.asp?contentid=48118& collectionid=3&contentarea=23810

Posted by pnhp at 03:33 PM | Permalink | Comments (0)

Contact: Art Taggart Coalition for Wisconsin Health phone: 608-833-8888 mobile: 608-217-9650 email: ataggart@facstaff.wisc.edu

Representative Mark Miller and Congresswoman Tammy Baldwin Team with The Coalition for Wisconsin Health to Introduce Universal Health Plan Bill

MADISON, WI, March 6, 2003 — Representative Mark Miller and Congresswoman Tammy Baldwin will join members of the Wisconsin Coalition for Health to introduce The Wisconsin Universal Health Plan bill at a press conference in the State Capitol Assembly Parlor on March 10, at 10am. State Senator Tim Carpenter will also be in attendance to introduce a companion bill proposing a single-payer health care program.

"Wisconsin's superior health care is at risk because double digit increases in health insurance premiums combined with economic uncertainty makes it increasingly difficult for employers to maintain their commitment to providing health insurance for their employees," states Mark Miller. "A single-payer system, as proposed in this bill, should allow expansion to all residents of the state and greater efficiency for providers."

The Wisconsin Universal Health Plan bill is co-sponsored by The Coalition for Wisconsin Health, a collection of more than 60 organizations from farm, labor, disability, faith-based, and senior organizations dedicated to providing health care as a fundamental right. The aim of the group is to provide comprehensive health care for every Wisconsin resident regardless of race, ethnicity, color, creed or economic standing.

"Insurance companies continue to ask government to provide coverage for those most in need of health care, while they use underwriting principles to skim the healthiest for their risk pools," explains Art Taggart, of the Coalition for Wisconsin Health. "If you are very healthy, insurance companies want your business; if you are very disabled, taxpayers provide your coverage. It is the working poor and those with pre-existing conditions who are left out in the cold." [more]

Speakers at the press conference will include:

-Representative Mark Miller, State (D), Assembly District 48 -Representative Tammy Baldwin (D), 2nd Congressional District -Senator Tim Carpenter (D), 3rd Congressional District -Art Taggart, Coalition for Wisconsin Health; Epilepsy Foundation South Central WI -Dr Franklin Stein, Professor Emeritus, University of South Dakota Medical School; Founding Editor, Occupational Therapy International -Dr. Linda Farley, Physicians for a National Health Program -James T. Wrich, Analyst, Health Systems Performance Co.

Dr. Linda Farley will represent concerned physicians on Monday: "Health Care is a service, not a commodity," Farley said. "Physicians must be committed to providing quality care to all the people based on their need, not on their ability to pay. The Wisconsin Universal Health Care bill would allow physicians and other health care workers to concentrate on the health of patients and populations, without the hassles of excessive paper work."

Select Features of The Wisconsin Universal Health Plan Bill

The Wisconsin Universal Health Plan is a comprehensive plan to provide quality health care to all Wisconsin residents-rich, and poor, young and old, regardless of health condition, medical history or employment status. By replacing over 700 different health insurers with a single publicly financed plan, it would eliminate waste and red tape. It would be administered at the state and local level, accountable to the residents of Wisconsin.

Administration: A single-payer, publicly funded program administered by the Department of Health, Planning and Finance under the guidance of the Wisconsin Health Policy Board

Coverage: Covers all Wisconsin residents regardless of pre-existing health condition, age, sex, race, sexual orientation, geographic location, employment or economic status.

Covered services: Hospital and clinic services; office visits and house calls; Services of physicians, dentists, social workers, and other licensed professionals; Prescription drugs; Health promotion and illness or injury prevention; Long term care, including home and nursing home care, and community health centers; Mental health services, and alcohol and other drug rehabilitation services

Freedom of Choice: Freedom for patients to choose health providers.

Quality and oversight: Sets up monitoring and oversight mechanisms in six regions of the state. Regional investigations of quality, access to medical services, and consumer complaints

Financing: Establishes Health Trust Fund in Department of Health Planning and Finance. All revenues earmarked for health care to be deposited into Fund, from which all providers are reimbursed.

Insurance Industry role: Health insurance coverage permitted for services not covered by WUHP.

Physicians for a National Health Program (PNHP) is a research and education organization with more than 10,000 members representing every state and specialty. PNHP was founded in 1987 and has physician spokespeople across the country. For contact information, call the national headquarters in Chicago at (312) 782-6006. Visit us online at www.pnhp.org. To interview a member of PNHP about the ever-growing national single-payer movement, contact Ida Hellander at 312.782.6006 or pnhp@aol.com

Also read today's USA TODAY op-ed by PNHP President Don Mccanne:

http://www.usatoday.com/news/opinion/editorials/2003-03-05-oppose_x.htm

Posted by pnhp at 03:01 PM | Permalink | Comments (2)

USA TODAY
3/6/2003
Editorial/Opinion

USA TODAY's view:

Affordable remedies ignored as nation's health woes soar

Perhaps the best measure of the depth of the nation's health care troubles is this: Amid terror warnings, possible war with Iraq, a faltering stock market and a sluggish economy, a new poll says the public's top worry is rising health care costs.

Some achievable steps:

* Lowering drug costs. * Cutting hospital bills. * Providing affordable insurance. * Helping consumers cut costs.

None of these cost-saving ideas alone will solve the nation's health care problems. But bipartisan cooperation to enact them could prime the pump for more comprehensive reforms, improve the competitiveness of the health care marketplace and make consumers more aware of medical costs.

The country's rising concerns about a broken health care system can't be ignored indefinitely. Small repairs today can pave a path for bigger solutions tomorrow.

For the full USA TODAY editorial: http://www.usatoday.com/news/opinion/editorials/2003-03-05-our-view_x.htm

Opposing view:

Nationalize health care By Don McCanne

The continuing rise in health care costs is proof that our existing system of competing health plans has been incapable of controlling costs. Decades of attempts to improve coverage through a hodgepodge of private plans and public programs have resulted only in higher costs and greater numbers of uninsured. Current proposals that build on our existing system promise only higher costs and the perpetuation of the profound administrative waste that is unique in the world. We spend more on paperwork in our health care system than we do for our entire military budget - almost $400 billion.

Single-payer national health insurance, by contrast, would slow the growth of health-care costs well into the future. And it would ensure that everyone has access to comprehensive health care services.

What do we really want out of our health care system?

* We want affordability. Placing our health care system on a single budget would provide a mechanism to finally corral health care costs for all of us.

* We want our health-insurance dollars to be spent on patients, rather than private-health-plan bureaucracies. By eliminating administrative waste caused by the health plans and the costly burden they place on the system, we would free up more than enough to pay for coverage of the uninsured and truly comprehensive benefits for all.

* We want our health insurance always to be there. With a universal insurance program, we would never lose coverage because of a change in employment, early retirement or a financial setback that makes premiums unaffordable.

* We want to be free to choose our physicians and hospitals instead of being penalized for failing to use the provider chosen by the insurance company.

* We want to have access to care whenever we need it rather than when and where the insurance company dictates.

The marketplace will not serve us well in health care if we depend on health plans. They would continue to compete based on the price of their premiums. But with rising costs, plans can keep their premiums competitive only by shifting costs to patients in the form of fewer benefits and greater out-of-pocket payments. This would threaten the financial security of those with the greatest health care needs.

On the other hand, competition based on quality would be beneficial. Since we would have free choice of doctors and hospitals, the providers themselves would be motivated to compete for patients based on the quality of their services.

A single-payer system, funded at our current level of spending, would provide high-quality, comprehensive, affordable health care for everyone. But we can achieve this only if we throw out the wasteful, ineffective middlemen - the health plans - and spend the money on patients instead.

Don McCanne, M.D., is president of Physicians for a National Health Program.

http://www.usatoday.com/news/opinion/editorials/2003-03-05-oppose_x.htm

Posted by pnhp at 02:59 PM | Permalink | Comments (0)

The Washington Post
March 5, 2003
The Associated Press
Report: Aetna Collecting Minority Data

Aetna Inc. has begun collecting data on the racial and ethnic backgrounds of some of its 14 million health plan members in what the insurer calls an effort to narrow the gaps in treatment between whites and minority patients, The Wall Street Journal reported.

Aetna said it is trying to understand differences in how white and minority patients get medical care, and to develop prevention, education and treatment programs to narrow the gap. But critics say collecting the data raises questions about patient privacy and racial profiling.

One concern is that insurance companies could use such information for underwriting decisions and "make it difficult for the people who need coverage to get coverage," said Clyde Yancy, a cardiologist at the University of Texas Southwestern Medical Center in Dallas, who has studied racial disparities.

The Hartford, Conn.-based company rolled out the initiative in 13 states and the District of Columbia in September, asking new members or those changing health plans or beneficiaries to voluntarily list their race or ethnic status on the application.

"There is a disparity under every rock and a disparity behind every tree," Aetna chairman and chief executive John W. Rowe told the paper in a story on its Web site. "We need to do something about it."

http://www.washingtonpost.com/wp-dyn/articles/A43387-2003Mar5.html

Comment: It is very difficult to see what clinical use Aetna would make with racial and ethnic data collected during the enrollment or underwriting process. Clinical interventions, such as disease management programs usually are initiated by identifying clinical problems through the claims process instead. Since responses are voluntary, this is a population sampling process and not a process designed for individual intervention.

It is unlikely that this information would be used for underwriting in the individual market. Although risk does vary with ethnicity and race, could you imagine Aetna sending a notice of higher premiums or even rejection because you're black? Although Aetna's business practices have often been insensitive to needs of patients, they're not dumb enough to institute a program that could provoke a boycott.

But this information could have important business value for Aetna in their group health plan markets. A significant sampling of race and ethnicity could indicate to them that there is risk of greater medical losses. Thus they could tailor the premiums, benefits and cost sharing to assure profitability in these "unfavorable" markets. This is a policy that assures that those with the greatest health care needs will also have the greatest financial exposure.

Although the insurance industry consumes an outrageous amount of our health care dollars, they are not providing a service but rather a disservice by compounding the inequities and injustices of our system. Why do we continue with policies that reward this amoral and even immoral industry? If we had our own single, universal, public program, we could assure that the appropriate extra resources required by groups that suffer from disparities would be directed to their needs.

But, instead, it looks like we'll continue to build on our current system that assures that John Rowe will continue to build his mega-wealth.

Sick! Sick!

Posted by pnhp at 02:59 PM | Permalink | Comments (0)

The White House
March 4, 2003
President to Announce Framework to Modernize and Improve Medicare

Excerpt from the Executive Summary:

Option 1-Traditional Medicare

Those who are satisfied with the current Medicare system will continue receiving their care as they do today with help for the high costs of prescription drugs. These beneficiaries will gain access to discounted drugs through a prescription drug discount card-estimated to achieve savings of 10-25% on the cost of prescription drugs-as well as coverage to protect them against high out-of-pocket prescription drug expenses. These new benefits will be provided at no additional premium.

Option 2-Enhanced Medicare

Enhanced Medicare will give seniors the same types of choices that are available to members of Congress and other federal employees. In every area of the country, Medicare beneficiaries will have multiple health plans from which to choose. These plans will offer prescription drug benefits, full coverage of preventive benefits, protection against high out-of-pocket drug costs, and cost sharing that does not penalize participants who need the most medical care. Again, the decision to choose Enhanced Medicare will be entirely up to each senior, and participants will be able to choose any doctor or any hospital they want for the treatment and care they need.

The President's framework will ensure that the benefits offered under Enhanced Medicare are sufficiently attractive to seniors, relative to traditional Medicare, to guarantee that Enhanced Medicare is a viable system.

Option 3-Medicare Advantage

Seniors will also have the option of enrolling in low-cost and high-coverage managed care plans, similar to those available today under Medicare. Medicare Advantage will include plans that offer a subsidized drug benefit, and all plans will be able to offer extra benefits, as many private plans do today.

Excerpt from the Conclusion:

To improve, Medicare must have the benefit of modern health care delivery systems and methods that have proven successful in the private sector. The President's initiative will introduce private sector innovation and competition to the Medicare system to help keep costs reasonable, ensure high quality care and begin to address Medicare's long-term financial challenges.

While Medicare must be modernized and improved to meet the needs of its current participants, the program must also be made sustainable for future generations. Given the financial challenges Medicare faces in the future, changes to the Medicare program we make today must not exceed our nation's means to deliver them tomorrow.

http://www.whitehouse.gov/news/releases/2003/03/20030304-1.html

Comment: To understand the administration's proposal, we must keep in mind what this program to "modernize" Medicare is intended to accomplish. Regardless of all of the rest of the rhetoric, the sole intent is to reduce the federal (taxpayer) contribution to the health care of the Medicare beneficiaries. Period. All of the wonderful, free-market rhetoric is designed to distract us from this precise goal. With that in mind, let's look at the three options offered (though not in order).

Option 1 - Traditional Medicare: The traditional Medicare program is inadequate. The lack of pharmaceutical coverage is a glaring example. The traditional Medicare program needs more funds, precisely what the administration is avoiding. So we will see no recommendations for an expansion of benefits in the traditional program.

But to meet campaign promises, they propose introducing a worthless discount prescription card, and they propose to provide the wealthy with protection for high drug costs by providing coverage only after spending many thousands of dollars on drugs. For very low income individuals, they'll cover up to $600 worth of drugs. It is uncertain if this paltry coverage reflects the value that they assign to the unfortunate individuals in this sector of society.

A second reason that they do not want to add more benefits to the traditional program is that want to use those benefits to lure beneficiaries out of the traditional program and into private plans.

Option 3 - Medicare Advantage: This is the current Medicare + Choice program. It was a failure. It worked only as long as the plans could limit their exposure to high costs by selectively marketing to a healthy sector. But the plans failed to provide the administrative efficiencies promised, and ended up costing the government more, on a risk adjusted analysis. The only way that it could be salvaged is to increase taxpayer funding beyond that of the traditional program, again the opposite of the administration's goal. They've decided to let this program fade away.

Option 2 - Enhanced Medicare: As promised, this is the proposal similar in design to the Federal Employees Health Benefit Plan, "the plan that the members of Congress have." This is basically the Breaux-Frist-Thomas-Jindal premium support proposal. It is a defined contribution concept, though some defenders dispute the terminology.

An important sentence in the White House release: "Beneficiaries who enroll in an average priced plan in their region would pay a premium for the medical portion of their coverage equal to the Part B premium." Clearly this confirms that individuals who desire more comprehensive benefits, or who wish to reduce their financial exposure, will have to bear the costs of that additional coverage in the form of higher premiums. So the wealthy are well cared for in this proposal.

What about those individuals who do not have the resources to purchase more comprehensive coverage? What will their program offer? A clue: "To provide an array of choices in benefit design and to encourage plan innovation, plans will be free to structure their offerings differently, provided the benefit meets a basic federal standard. "Plan innovation with flexibility in offerings" should make us worry. Spartan plans will surely become the "averaged priced" plans. And we can only speculate that an administration that doesn't have any money for anything else, certainly will not have enough money to fund more than the very lowest tier of services that is the "basic federal standard."

Then the politicians will ask why we should be spending more on traditional Medicare patients than we do on the "basic federal standard." And of course their solution will be to cut funding of the traditional program.

This scheme does not reduce the costs of health care; it merely shifts the costs from the federal government to the Medicare beneficiary. The majority will be unable to afford their portion of costs should they be faced with a major medical disorder.

Should Medicare policy be crafted to improve the utilization of resources for the benefit of patients, or should it be designed simply to reduce federal funding of the program? It looks like the Bush administration has decided that Medicare should be added to list of programs to be sent off to the guillotine for a blunt trimming.

Posted by pnhp at 02:57 PM | Permalink | Comments (0)

For Immediate Release Contact: Beth Capell

California Physicians Alliance Supports SB921 (Kuehl)

Health Care for Every Californian

Today, James G. Kahn, M.D., M.P.H., author of one of the nine Health Care Option Papers, and treasurer of the California Physicians Alliance joined Senator Sheila Kuehl (D-Santa Monica), other legislators and representatives of other organizations in announcing their support for SB921 by Senator Kuehl.

"In a time of skyrocketing health care costs when millions of Californians lack health coverage, SB921 would cuts costs by reducing administrative waste and refocusing health spending on health care, not overhead," said Jim Kahn.

SB921 would provide health coverage to every Californian---every Californian would have the health care they need when they need it---whether their employer offered health coverage or not, whether they were between jobs or not, whether they were a young person just starting out, or somebody in their 50's forced into early retirement.

SB921 creates a system of public financing of health care, similar to that used for Medicare. An independent analysis of the research by Kahn et al demonstrated that employers who do the right thing and buy health insurance now would save money under this system. So would most Californians.

As for Medicare and unemployment insurance, employers would pay a tax to cover the cost of health care. Employees would also make a contribution. SB921 also includes increased taxes on alcohol and tobacco to supplement the payroll taxes and employee contributions.

SB921 takes some of the best aspects of HMO reform and applies them to the entire health system: putting the doctor in charge of health care, evaluating whether care is medically appropriate, assuring that consumers have a voice in the health care system.

The California Physicians Alliance is a non-profit, public interest group of physicians and other health activists committed to universal access to quality, affordable health care for all Californians. CaPA was instrumental in creating HMO reforms enacted in California in 1999.

The full text of the bill is available here: http://info.sen.ca.gov/pub/bill/sen/sb_0901-0950/sb_921_bill_20030221_introd
uced.html
http://info.sen.ca.gov/pub/bill/sen/sb_0901-0950/sb_921_bill_20030221_introd
uced.html

Posted by pnhp at 12:02 PM | Permalink | Comments (5)

Uwe Reinhardt responds to Deborah Socolar on her comments about price disparities:

In connection with price disparities in health care, I wonder what Deborah Socolar means when she uses the term "free market" in her sentence:

"If it were a free market, competition would mean prices would tend to converge (as happens with, say, prices in pizza parlors)."

A distinguishing characteristic that sets pizzas apart from, say, coronary bypasses is that the former can, in principle, be resold among customers while a CABG cannot. Absent a resale market for CABGs (and most other health services), the stage is set for price discrimination, that is, charging different customers different prices for the same thing.

Now, if CABGs and other health services were perfectly standard commodities that are purchased in a national market (i.e., Jones does not care whether his or her CABG is procured in Holy Mercy in San Diego or Apex Hospital, Inc. in Dallas or Womens and Brigham in Boston), then there might still be price convergence. That is why hotel rates quoted to conventions tend to converge across areas with similar climatic and other characteristics.

But CABGs and other health care are not at all perfectly standard commodities and they are not traded competitively over large national markets. Price convergence in a "free" (unregulated?) market would be unlikely to obtain.

Only in highly regulated market with either administered prices set more or less unilaterally by the buy side (Medicare, Medicaid) or uniform prices negotiated by large bodies representing individual buyers and seller, respectively, (Germany) would price discrimination disappear. Even then price might or might not reflect costs.

Uwe Reinhardt

Posted by pnhp at 02:25 PM | Permalink | Comments (0)

Aetna
Press Release
February 11, 2003
Aetna Reports Fourth Quarter And Full-year 2002 Results

"In 2002, Aetna improved its financial performance," said John W. Rowe, M.D., chairman and CEO. "This success was built on a seven-point reduction in the medical cost ratio (MCR), as well as lower administrative costs. This decline in MCR was driven by three factors: reduction of membership with historically higher MCRs ... (premium increases)... (and changing contracts and benefits).

Full-year 2002 results for Health Care show operating earnings, excluding other items, of $361.6 million, compared with an operating loss, excluding other items, of ($161.9) million for full-year 2001, primarily reflecting improved underwriting results, driven by an increase in the premium yield and a decline in the medical cost trend, combined with continued reductions in operating costs and a decrease in amortization of intangibles.

"Aetna delivered on its promises in 2002, and we believe the company is now firmly re-established as a top-tier competitor in the health care arena," President Ronald A. Williams said. "Our broad operational goal for 2003 and beyond is to build on our competitive advantages and grow profitably."

http://www.aetna.com/news/2003/pr_4thquarter2002_earnings.htm

Comment: Building success on reduction of membership with higher medical cost ratios, and increasing the premium yield with a decline in medical cost trends was accomplished by withdrawing from high cost markets and pricing plans with high cost patients out of the market. Eliminating beneficiaries that actually need health care will allow Aetna to fulfill its goal of building on their competitive advantages and grow profitably.

Should we criticize a corporation for reducing losses and improving profits? No. It is their obligation to their shareholders to do precisely that.

Should we criticize health care policymakers for insisting that we continue to build on this system that thrives by excluding from coverage those with the greatest health care needs? No, criticism is not enough. We need to dismiss them and replace them with policymakers that will design a health care funding system that has a mission of actually meeting the health care needs of all of us.

Posted by pnhp at 01:24 PM | Permalink | Comments (0)

The New York Times
March 2, 2003
A New Health Plan Works, at Least for the Healthy
By Beth Kobliner

Last fall, Mrs. Welborn, 32, a senior training specialist in corporate development, signed up for a new kind of health coverage, called a health reimbursement arrangement, or H.R.A. As part of the plan, her employer, CompuCom Systems, an information technology service provider in Dallas, has given her a $2,000 health care savings account that she can use to pay for medical care.

But Mrs. Welborn's new plan also comes with a hefty deductible of $3,400. That means that if she spends more than her allotted $2,000 in the account this year, she will be liable for the next $1,400 of expenses. After she reaches the deductible, the insurance plan kicks in; it will cover 80 percent of costs, if network doctors are used, and 60 percent if not.

But if any of the $2,000 remains in her account at year-end, she can add it to the next $2,000 CompuCom will set aside for her in 2004. Mrs. Welborn... can have a maximum of $6,000 in her account.

Consumer-driven plans are variations on P.P.O.'S and H.M.O.'s, but with two important differences: they carry considerably higher deductibles, often around $1,500 for individuals and $3,000 for families; and employers cushion these higher deductibles at the front end, by financing individual cash accounts ranging from a few hundred to several thousand dollars.

http://www.nytimes.com/2003/03/02/business/yourmoney/02MEDS.html

Comment: Medical savings accounts (MSAs), tax free medical accounts backed up by high deductible (catastrophic) insurance, have long been supported by those who claim that we will bring health care costs under control only when we make patients sensitive to costs by spending their own funds. Once their medical savings are depleted, then the catastrophic plans will cover all costs. But this is really a fantasy, as we'll see below.

For several reasons, insurers and employers have been reluctant to offer these products. But an IRS ruling last year authorized the version called health reimbursement arrangement (HRA). One of the features that made HRAs more attractive is that the unused funds could be rolled over from year to year. It is important to note that employers retain ownership of the HRA. Unspent funds on job termination are not converted into a cash or retirement benefit for the employee, but remain with the employer. So it really is a pooled fund source with a low spending cap per individual or family. Since the accumulation of funds will stop when the maximum is reached ($6000 in the example in the article), the family would be motivated to be sure that the funds are spent or they will fail to receive additional contributions and will eventually lose what's left anyway. Since most healthy families spend less than the amount placed in the HSA, they will be motivated to increase their utilization of health care services, the exact opposite of the intended result.

The high deductible coverage offered with these HSAs also raises concerns. These catastrophic plans are not indemnity plans that "cover 100% of costs after the deductible is met." They are PPO and HMO managed care plans, using contracted providers. Some plans may allow patients to use their own non-contracted providers, but only with severe financial penalties.

Let's look at an example using the numbers in the article: a $2000 HSA, with a $3400 deductible, and then a PPO with 80% for network providers and 60% for providers outside of the network. What is not mentioned is that this is 80% or 60% of the allowed fee. The contracted provider is required to adjust off the disallowed balance, but, of course, the non-contracted provider can demand the full fee.

Now let's say that the patient needs an $85,000 coronary bypass. The university center in town has a cardiovascular surgery program noted for its excellent outcomes. The other hospital in town is being investigated for doing a very large number of bypass surgeries that appear to have been unnecessary. But because of the higher cost of care at academic centers, the charges will be $108,000 instead. Although this may be a somewhat extreme example, it is realistic. And most of us would certainly opt for what we perceive to be better care, especially for our loved ones.

How do the numbers work out? Let's make one more assumption. The PPO has contracted with the hospital under investigation for a fee of $56,000 for the package, a reasonable fee since the PPO can offer that facility a high volume of insured patients. But the PPO has repeatedly failed to negotiate a similar contract with the academic center, which then remains a non-contracted provider.

The numbers? The employer funded HSA pays the first $2000. The patient pays the next $1400, when the deductible is met. The allowed amount, $56,000, minus the deductible of $3400, leaves a covered amount of $52,600. Since the center is not contracted, the PPO pays 60% or $31,560 and the patient pays $21,040. But the patient is also responsible for the disallowed charges of $108,000 minus $56,000, or $52,000. So this HRA with a catastrophic plan that "covers expenses after the deductible is met," results in an out-of-pocket expenses for the patient of a total of $84,240. That is quite a tab for an $85,000 procedure, especially for a family with an income of $42,228 per year (median household income 2001, US Census Bureau).

Under the best circumstances, the patient would pay the $1400 share of the deductible and 20% of the contracted rate, with the balance being adjusted off. That would still amount to $11,920, an almost unaffordable amount for a median income household.

Who would elect these plans? Individuals that shop for plans based on premium alone might select them because the premiums for high deductible coverage are lower. Those that are better informed may still elect these plans, gambling that they would remain in good health. But those that develop a major acute medical problem will lose their bet. Individuals with significant chronic disorders would not select HSAs but would select more comprehensive plans. Concentrating higher cost patients into more comprehensive plans will drive up premiums, threatening affordability of comprehensive coverage for the rest of us.

Private indemnity insurance has been priced out of the market and is gone forever. The fragmented system that we are left with can only perpetuate and compound the inequities that characterize our system today. We already have enough money in the system to provide comprehensive services for everyone, but the only way we can ever obtain value for that already invested is to establish a single, equitable risk pool. Why do we keep delaying the inevitable?

Posted by pnhp at 09:14 AM | Permalink | Comments (0)

California State Senate Bill Number: SB 921 February 21, 2003

SB 921, as introduced, Kuehl (Sen. Sheila Kuehl). Single payer health care coverage.

This bill would establish the California Health Care System to be administered by the newly created Health Care Agency under the control of an elected Health Care Commissioner. The bill would make all California residents eligible for specified health care benefits under the California Health Care System, which would, on a single-payer basis, negotiate for or set fees for health care services provided through the system and pay claims for those services.

http://info.sen.ca.gov/pub/bill/sen/sb_0901-0950/sb_921_bill_20030221_introd uced.html

Comment: Sen. Kuehl's bill is based on the findings of the California Health Care Options Project which demonstrated that all residents of Californian could have affordable, comprehensive health care coverage merely by eliminating the administrative excesses of the current system and establishing a single, publicly administered payer for health care services.

Sen. John Burton is also introducing a pay-or-play employer mandate which apparently is receiving the support of AFL-CIO and the California Medical Association.

Another measure (AB 30, Richman) would "reduce state funding for county hospitals and safety net providers" and transfer those funds to the Medicaid and SCHIP programs. Another proposal (AB 293, Daucher) would allow small businesses to provide insurance to employees working a minimum of 40 hours per week, using an hour of overtime to help pay for health care coverage.

Obviously, the debate in California will be between single payer and an employer mandate. Although the leadership of AFL-CIO and CMA may be attracted to the "politically feasible" employer mandate model, union members and physicians need to take a careful look at both proposals. They will see that the single payer program will not only provide greater benefit for all patients in California, but it will also provide greater benefit for union members and physicians. Union members will have greater health and financial security, and physicians will have freedom and the resources to provide the care that their patients need.

Posted by pnhp at 09:45 PM | Permalink | Comments (0)

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

To Quote of the Day list members:

It should not have surprised me to receive the responses that objected to the poetry expressing opposition to the war, but it did. I mistakenly believed that those who support health care reform would also support activities designed to prevent the premature death and suffering characteristic of a war that most of the citizens of the world believe is avoidable.

For those that did complain, I wish to thank you for being willing to express your thoughts on this highly controversial topic. I also wish to apologize in advance for the fact that my comments to follow will not end the controversy.

I sent the message out after the Bush administration announced a second condition for preventing the war, a regime change in Iraq. Since it seems that we are only days away from war, I believed that our stridency must increase. I believe that an effort to prevent this war must be the first priority of everyone at this moment. Our work on health care reform can continue, but it is a task that will never be completed though, hopefully, we will have major breakthroughs such as the eventual establishment of a universal single payer.

The decision to send the poems to the Quote of the Day list was mine and mine alone. Although I am president of Physicians for a National Health Program, and most of the messages are posted on the PNHP website, technically they are my personal project and not a project of PNHP. It is appropriate that PNHP publishes my comments since my personal views coincide precisely with the policies developed and supported by PNHP. I'm not saying that I'm always right on target since I'm only human, and I have no staff to critique my views before I send them out. But I am saying that, to those who were offended, please direct your ire exclusively toward me and not to PNHP.

Because I sent the anti-war message to a list that is for health policy issues, I certainly can be criticized for having sent out spam. And for that I do sincerely apologize.

Although I erred in my selection of the forum in which to express my views, I did not err in my expression of those views. For speaking up on this issue, I cannot apologize.

Many undoubtedly were offended by the particular poems that I selected from the thousands on the Poets Against the War website. The poems suggested that the president's decision-making process on the issue of the war is no more sophisticated than that of a young child. With all of the options available, our president is down to a list of only two. Either Saddam Hussein walks, or we attack. Even a child can understand that expanded inspections until hell freezes over would be a much better option, but that has already been rejected by President Bush.

Ardent supporters of Mr. Bush might be expected to be offended by my remarks. But I am more offended by their callous disregard of the people of Iraq and disregard of our standing in the international community. No political personality is worth protecting at that price.

I will not use the Quote of the Day list for any further comments on the war. I intend to limit the list to health policy issues. But for those of you who believe that I have already exceeded my bounds to the degree that you want off the list, you can unsubscribe at http://two.pairlist.net/mailman/listinfo/quote-of-the-day, or you can send me an e-mail directly at don@mccanne.org.

For those who agree with me, more stridency please!

Don McCanne

Posted by pnhp at 10:09 AM | Permalink | Comments (0)

BY KAY MCVAY
Special to The Examiner
    TENNESSEE Sen. Bill Frist is undoubtedly a good surgeon and a handy provider of roadside emergency medical service, but the plan he and President Bush are cobbling together for Medicare contains neither a useful diagnosis of the country's current healthcare infirmity nor a prescription for getting us out of our current healthcare blind alley.

    The Bush-Frist approach will hardly move us any closer to a genuine solution. In a hospital setting, to prescribe a spinal adjustment when radical surgery is called for is to ignore the injunction to first of all do no harm.

    Although the full details of the president's Medicare plan are yet to be revealed, it is evident that the administration seeks to "promote competition" in Medicare and eventually turn it into a program looking more and more like private healthcare insurance.

    To most Americans, anything that sounds like more HMO-healthcare is going to be immediately suspect, but the White House and some in Congress imagine such an aversion can be overcome by linking a broad scheme to profoundly revamp Medicare with the popular appeal of adding prescription drug coverage.

    The core of the argument is that competition for enrollees between regular fee-for-service Medicare and private insurance will result in lower costs for healthcare coverage.

    However, with the costs of drugs and other elements of healthcare delivery skyrocketing, the readily available instrument enabling private insurers to "hold down costs" is diminishing services.

    The history of the managed care "revolution" -- which the White House would now superimpose onto Medicare -- is one of drive-through mastectomies, restricted access to specialists, physician speedup, decreased skilled nursing care and shuttered inner-city and rural medical facilities.

    Without some action to harness healthcare costs, they will only continue to rise.

    The only significant change under the Bush plan would be that Medicare funds would be channeled through -- and siphoned off by -- private insurers.

    Moreover, HMO bureaucracies, advertising expenditures and enormous executive compensation arrangements will remain major contributors to spiraling healthcare delivery costs.

    Managed care and health maintenance organizations were supposed to make healthcare more accessible and affordable.

    Nothing of the sort has happened. Costs continue to rise, far outstripping the general rate of inflation; out-of-pocket expenses for insured patients continue to increase; personnel cutbacks are undermining care quality; and 44 million people have been priced out of healthcare insurance.

    The way out of the crisis and past these smoke and mirror "reform" proposals is recognition that the private insurers are superfluous. That is, they are not needed.

    Most of the industrialized world and much of the not-so-industrialized world has been able to do without them for quite a while. They have also been able to impose and enforce controls on healthcare cost inflation.

    Of course, this has meant no profits to be reaped in a healthcare "market." In the weeks and months ahead, those currently rewarded handsomely by the healthcare industry will be all over Washington and in our faces continually extolling the virtues of consumer "choice" and healthcare "competition" as they line up support for the Bush-Frist plan to get rid of Medicare as we known it.

    It was a tremendous accomplishment for our country to enact legislation in 1965 to guarantee that the elderly in retirement would no longer have to be in a state of continual insecurity when it comes to healthcare.

    Medicare is a successful and very popular program. People who have paid into the program over their working lives have every reason to expect the benefits will be there when they need them.

    What we need now is a plan for shoring up and expanding Medicare, adding a provision for full prescription drug coverage coupled with a thoroughgoing discussion of what we need in a healthcare system and how to get there.

    For many of us, this will lead in the direction of a comprehensive, universal "single-payer" type system that guarantees healthcare as an entitlement.

    Comment: letters@examiner.com

    Kay McVay, R.N., is president of the California Nurses Association.

http://www.examiner.com/opinion/default.jsp?story=op.mcvay.0221w

Posted by pnhp at 12:07 PM | Permalink | Comments (0)

Although this message seems to be a departure from the topic of health policy, what could be more unhealthy than war?

On March 5, 2003, about 15,000 poems will be presented to members of Congress By Poets Against the War. The poems are available at: http://www.poetsagainstthewar.org/

David Budbill

EASY AS PIE

The Emperor divides the world
into two parts:
the Good and the Evil.

If you don't want to accept that,
The Emperor says
you are Evil.

The Emperor declares himself
and his friends:
Good.

The Emperor says as soon as
Good has destroyed Evil,
all will be Good.

Simple as one, two, three.
Clear as night and day.
Different as black and white.

Easy as pie.

_______________________________________________

Bruce Arthurs

This Is The Day

This is the day.
This is his Big Day.
This is the Biggest! Bestest! day
of his life.

This is the day
he will be remembered for.
This is the day
his father's folly is erased.

This is the day
the naysayers are silenced.
This is the day
their numbers could not stop.

This is the day
the missiles will fly.
This is the day
when ancient cities burn.

This is the day
collaterals are damaged.
This is the day
that Jesus will applaud.

This is the day
his name becomes immortal.
This is the day
he finally shows them all.

This is the day.
This is his Big Day.
This is the Biggest! Bestest! day
of his life.

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