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November 30, 2004

A National Health Insurance Program for the U.S.

A National Health Insurance Program for the United States - The country must abandon its fragmented system
By Don R. McCanne
PLoS Medicine - November 2004

The continuing deterioration of affordability, coverage, and quality in health care makes it imperative that United States policymakers broaden their reform efforts beyond the ineffectual tinkering of incrementalism. A universal, single-payer, publicly funded and publicly administered program of social insurance would ensure access to affordable, comprehensive, high-quality health care for all. It should be the standard by which any other proposals are judged. If a better proposal can be crafted, now is the time to do it. People are dying while we delay.

http://medicine.plosjournals.org/archive/1549-1676/1/2/pdf/10.1371_journal.pmed.0010039-S.pdf

Comment: This article discusses the characteristics of the U.S. health care system that result in mediocrity in spite of our very high spending. And then it discusses options for reform.

As an open access journal, readers are encouraged to download articles and use them for their own purposes. Some may find this article to be useful in educating the public on the rationale of national health insurance.

This is the second issue of PLoS Medicine, a peer reviewed, open access, international, multidisciplinary journal of medicine from the Public Library of Science, founded by Nobel Laureate Harold Varmus and his colleagues. Their goal is to have PLoS Medicine become recognized as a premier journal of medicine, but with an important difference. All published material will be immediately available online without cost to anyone. This ensures that the very latest information and research in medicine is always available, without financial barriers, even to poor third world countries.

For more information, including free online subscribing:
http://medicine.plosjournals.org/perlserv/?request=index-html

PLoS Medicine:A National Health Insurance Program for the United States

The continuing deterioration of affordability, coverage, and quality in health care makes it imperative that United States policymakers broaden their reform efforts beyond the ineffectual tinkering of incrementalism.

Kindly go to the below link to read Dr.McCanne’s interesting article published in PLoS Medicine
Please click here

Uwe Reinhardt on what makes America great

Uwe Reinhardt, Ph.D., Professor of Economics and Public Affairs, Princeton
University (personal communication):

Don: Attached is a portrait of what makes America great. Instead of using the coercive power of government to make you and me pay for her dental
care, this lady uses a pair of pliers to pull her own tooth. One just has to admire it. It keeps our tax rate (as % of GDP) the lowest in the OECD and our economy strong.

Best,

Uwe

(Rather than being included as an attachment to this message, the photograph can be viewed at this link to The New York Times:
http://www.nytimes.com/2004/12/28/business/28dental.html)

Comment: It is astounding that, in the world’s wealthiest nation, aversion to taxes is a more important driver of policy than is the health of its people. This is particularly troublesome as we witness the debate over the “stinginess” of our response to the unfathomable tragedy of the Tsunami.

In his Christmas message to the nation, President Bush said, “By volunteering our time and talents where they are needed most, we help heal the sick, comfort those who suffer, and bring hope to those who despair, one heart and one soul at a time.”

And today the president said, “In this case, I think it’s very important for Americans who want to give to provide cash to organizations that will be able to focus resources and assets to meet specific needs,” and, “There are many NGOs now involved that understand what is specifically needed to meet the needs of these countries.”

Volunteers and nongovermental organizations (NGO) do play an important role
in society and are to be praised for their very noble efforts. But they can never replace the duty of the government to make every effort to adequately address these very vital issues. The impact of charity and volunteerism remains miniscule when compared to the capability of a wealthy nation and its government resources.

We can bring hope to one heart and one soul at a time by volunteering to lend our pliers when the need is great. Or we can adopt national policies that would bring hope to all hearts and all souls. With tax rates in line with other OECD nations, we would still have the greatest personal wealth, but would also have the capability to do much more to ensure the health of all of our citizens and of the citizens of the world.

Addendum: On a positive note, the article, “U.S. Health Care Spending In An
International Context” by Uwe E. Reinhardt, Peter S. Hussey and Gerard F.
Anderson, tops the list as the most frequently viewed article on the Health
Affairs website. At least the health policy community is interested in learning why we spend so much and receive such mediocrity in health care. The article can be accessed at: http://content.healthaffairs.org/cgi/content/abstract/23/3/10

There is hope.

November 29, 2004

This year, Ontario may pass Michigan in making vehicles

The New York Times
November 27, 2004
This Year, Ontario May Pass Michigan in Making Vehicles
By Danny Hakim

Michigan has been the heart of the auto industry since Henry Ford started mass-producing the Model T a century ago, but the Midwestern state is poised to be surpassed by Ontario.

The Canadian province is on course to pass Michigan this year and become the
biggest auto-producing state or province in North America, according to Ward’s Automotive, which tracks auto production data.

Canada is attractive, in part, because of its nationalized health care system, which negates perhaps the largest competitive burden faced by domestic manufacturers. G.M. spends roughly $1,400 a vehicle produced in the United States on health care, more than it spends on steel.

http://www.nytimes.com/2004/11/27/business/worldbusiness/27ontario.html?ex=1102605931&ei=1&en=60fbf9a152ab4bec

Comment: Old news. The costs of the health benefit programs of U.S. auto
manufacturers result in less competitive pricing of their products. But this remains in the news because the saga grows worse day by day.

How long will U.S. businesses continue to tolerate this burden?

——————————————————————————————————————-

Message: 2
Date: Tue, 30 Nov 2004
Subject: PLoS Medicine - National Health Insurance for the United States

PLoS Medicine
November 2004
A National Health Insurance Program for the United States
The country must abandon its fragmented system
By Don R. McCanne

The continuing deterioration of affordability, coverage, and quality in health care makes it imperative that United States policymakers broaden their reform efforts beyond the ineffectual tinkering of incrementalism. A universal, single-payer, publicly funded and publicly administered program of social insurance would ensure access to affordable, comprehensive, high-quality health care for all. It should be the standard by which any other proposals are judged. If a better proposal can be crafted, now is the time to do it. People are dying while we delay.

http://medicine.plosjournals.org/archive/1549-1676/1/2/pdf/10.1371_journal.pmed.0010039-S.pdf

Comment: This article discusses the characteristics of the U.S. health care system that result in mediocrity in spite of our very high spending. And then it discusses options for reform.

As an open access journal, readers are encouraged to download articles and use them for their own purposes. Some may find this article to be useful in educating the public on the rationale of national health insurance.

This is the second issue of PLoS Medicine, a peer reviewed, open access, international, multidisciplinary journal of medicine from the Public Library of Science, founded by Nobel Laureate Harold Varmus and his colleagues. Their goal is to have PLoS Medicine become recognized as a premier journal of medicine, but with an important difference. All published material will be immediately available online without cost to anyone. This ensures that
the very latest information and research in medicine is always available, without financial barriers, even to poor third world countries.

For more information, including free online subscribing:
http://medicine.plosjournals.org/perlserv/?request=index-html

November 28, 2004

Employers try shifting health costs

The Boston Globe
November 25, 2004
Employers try shifting health costs
Plans ease sting for those at lower end of pay scale
By Kimberly Blanton

To make healthcare more affordable to employees of all incomes, companies like Wachovia Corp… are adopting what are called salary-based health plans. Under the plans, employers pass on more of their rising healthcare costs to well- compensated executives than they pass on to lower-paid workers who can’t absorb the dramatic premium increases. Beginning Jan. 1, Wachovia will pass on larger premium increases to its executives around the country than to, say, its bank tellers.

Liberty Mutual is putting in place a salary component in an overhaul of its entire employee health plan designed to rein in future health expenses… Employees on the family plan who earn less than $50,000 will pay a $300 annual deductible, and their out-of-pocket costs for treatments will be capped at $1,500 per year. If their salaries fall between $50,000 and $99,999, the family deductible rises to $750, and maximum out-of-pocket costs rise to $2,250.

Executives earning $100,000 or more pay the most for a family plan: a $1,500 deductible and $4,500 out-of-pocket. In contrast to Liberty, most employers use tiered salaries only to set premium levels or annual premium increases.

“We wanted something that would not be way out there in terms of peoples’ ability to pay,” said Helen Sayles, senior vice president of human resources. “We felt it was the right thing to do.”

http://www.boston.com/business/articles/2004/11/25/employers_try_shifting_health_costs/

Comment: One of the more important goals of comprehensive health care reform is that the funding of health care should be equitable. Considering the relatively high costs of health care today, lower income individuals are not able to fully fund their portion of an appropriate level of health care utilization. To achieve equity, higher income individuals would pay more into the system.

It is certainly admirable that employers are attempting to establish equity within our fragmented system of funding care. Unfortunately, these efforts within small microcosms will amount to only a tiny mini-step towards health care equity for all of us.

The tax system provides the most effective agency for equitable funding of health care for everyone. Tax policies such as tax deductibility or tax credits can be developed to improve equity. But if applied to our current fragmented system, we would see a perpetuation of the inequities of thousands of plan designs with varying deficiencies in coverage or even total lack of coverage. Also our fragmented system is not adept at reducing the waste of administrative excesses nor the waste of ineffectual technological excesses.

Let’s follow the example set by these compassionate employers, but go them one better. Let’s support an equitable health care system for everyone:publicly funded social insurance with simplified public administration.

November 27, 2004

Healthcare as a moral imperative

The Boston Globe, November 27, 2004
Healthcare as a moral imperative
By James J. Mongan  

This article was adapted from remarks made Nov. 16 at the Blue Cross Blue Shield Foundation Summit on Access.

AFTER AN ELECTION season in which health care took a back seat to the Iraq war and gay marriage, it is refreshing to see that universal coverage for the uninsured has moved to center stage in Massachusetts.

The most important thing to do to move the universal health insurance issue forward in Massachusetts and across the country is to start with a frank discussion about funding. And I would argue, to address the funding issue, we ought to start a real dialogue about values.

As an analysis by the Urban Institute for Blue Cross Blue Shield Foundation’s Roadmap to Coverage points out, providing universal coverage costs money, beyond what we are currently spending — in the form of taxes to pay for subsidies, or employer mandates which are in effect taxes.

The elephant in the room in this discussion is, and has been for 30 years, how to get public support for additional revenue.

This is not just a public finance issue, it is a real values issue. Specifically, in a supposed time of ascendancy for “moral values,” I’d ask what happened to “social justice” as a moral value. I’d ask why we aren’t focused on social justice issues such as poverty, retirement security, and health insurance at the same time that we focus on issues like gay marriage and abortion. You see, I think I know why social justice issues get left behind — because dealing with these issues takes money — our tax money to help other people.

As we as a nation moved beyond the Depression, World War II, and the poverty program and civil rights struggles of the 1960s, we became, over the past 30 years, a relatively affluent, consumer nation and began to focus more on our own needs and wants.

It has been an age of individualism or self-centeredness or perhaps even selfishness. This culture fed the driving political force of the past 30 years — the antitax movement.

The antitax tide swept social justice issues aside, and left them behind in its wake. As a result, in recent years, every politician from the Courthouse, to the State House, to the White House feels they must run on an antitax platform. Just look at the consequences:

Our national tax level, as a percent of the gross domestic product, is at the lowest level since 1959.

In our state, tax cuts over the past 12 years have left us with $3.8 billion less in state revenue, which could have been available for covering the uninsured. We now rank 47th out of 50 in taxes and fees paid as a share of personal income.

Let’s look at what happened in Washington three years ago, when we passed a $1.6 trillion tax cut. We could have taken another path, and passed a $1 trillion tax cut, the largest in history, and used $600 billion to fund a comprehensive health insurance program for a decade.

When Uwe Reinhart, professor of economics at Princeton University, talks about that tax cut, he says budget decisions like this are like a memo to God. Reinhart says our nation’s memo said, “Dear God, we had to decide between health insurance and a tax cut, and we took all the money as a tax cut. We hope this pleases you — signed a grateful nation.”

After 30 years of waging the battle for broader health insurance, I am convinced the debate over universal coverage is more about values than it is about specific plans. If the resources were made available, we could easily develop a plan. We should focus on the question of what happened to social justice in an era of moral values. We should all look in the mirror.

Dr. James J. Mongan, who was associate director of the White House domestic policy staff in the Carter Administration, is President and CEO of Partners HealthCare.  
            
    

 

November 24, 2004

Taipei:Researchers discuss gaps in medicare

FAIR CARE: Academics and activists discussed changes to the health insurance program to ensure that all citizens receive medical coverage
By Cody Yiu
STAFF REPORTER
Wednesday, Nov 24, 2004,Page 4

A panel of academics and social welfare activists yesterday discussed whether National Health Insurance program should be converted into a social welfare system available to all citizens.

The panel discussion, held by the Creation Social Welfare Foundation, sought to determine why some people had not been covered by so-called universal health insurance.

According to the study, three groups of people do not receive health coverage: those who live abroad, young adults between the ages of 20 and 30 who change jobs frequently and people who cannot afford to pay insurance premiums.

“The first two groups do not have financial reasons for not being insured, the last group, which is made up of about 230,000 individuals, is not insured due to economic reasons. They may have unstable incomes, be unemployed or have a low social status,” said Lin Ji-Ping, a researcher at the Academia Sinica’s Research Center for the Humanities and Social Sciences, who participated in the study. These 230,000 individuals account for one-quarter of the total uninsured population, according to the study.

The Judicial Yuan’s Grand Justice Interpretation No. 472 (Jan. 29, 1999) stipulates that the state shall give appropriate assistance and relief to those who cannot afford to pay premiums, and shall not refuse to pay benefits, in order to fulfill the constitutional purposes of promoting national health insurance, protecting the elderly, the infirm and the financially disadvantaged.

The Council of Grand Justices provides legal interpretations of the Constitution.
Based on the interpretation, the academics said that the term national health insurance should be defined more clearly.

“In Taiwan, the emphasis of this health insurance policy is placed on the word insurance, and not on the word national [universal]. Therefore, it is an insurance system, not a social welfare system. However, what this particular interpretation by the Grand Justices says about national health insurance is in contrast with the actual practice,” said Lin Wan-I, a professor of social work at National Taiwan University.

The National Health Service (NHS) of the United Kingdom, Lin said, functions as a social welfare system.

“The NHS does not work like an insurance program, but as a social welfare system, and the focus of the UK’s system is on all,” Lin said.

Lin suggested that a portion of tax revenues be allocated to Taiwan’s national health program if the program was in fact meant to serve the entire population.

“In Sweden, about 7 percent of one’s income goes to the national health program. Taiwan could adopt this structure in which money flows out of one’s income [as tax] and into the program, instead of actually having to pay for premiums. This way, the entire population would be included in the health program,” Lin said.

Michael Chen a social welfare associate professor at National Chung Cheng University, suggested treating the three groups that fall outside the system like the unemployed in terms of insurance coverage.

Chen explained that the current national health insurance policy covered unemployed people for a maximum of 30 weeks. However, at least half of the unemployed population was actually out of work for a longer period, and therefore the policy should be re-adjusted.

http://www.taipeitimes.com/News/taiwan/archives/2004/11/24/2003212340

Implications for Nonprofit Organizations and Those They Serve

Johns Hopkins University
Center for Civil Society Studies
Institute for Policy Studies
October, 2004

The Health Benefits Squeeze:Implications for Nonprofit Organizations and Those They Serve
By Lester M. Salamon and Richard O’Sullivan

Conclusion: The Silent Tax

Escalating health insurance premiums have emerged as a silent tax on the American workforce, offsetting by a substantial margin whatever advantage
workers received as a consequence of recent federal tax cuts and contributing to the reluctance of employers to add new workers to their rolls.

For the most part, attention to the impact of these rising healthcare costs has focused on the business sector. But as the research reported here makes clear, nonprofit organizations have not been immune to these pressures. To the contrary, there is evidence that they have been particularly hard hit, perhaps because they are generally smaller in scale or lack access to the benefit management specialists that seem so important in keeping healthcare costs in check in an increasingly complex healthcare market.

To date, nonprofit managers have succeeded in shielding those they serve from the impact of escalating healthcare costs except for a growing need to introduce or increase service fees. To do so, however, nonprofit managers have had to shift the costs on to their employees - through increased premiums, co-pays, and cost-sharing or through reduced raises or other benefits. In the process, however, they may be undermining one of the few concrete advantages of nonprofit employment - the generally benign human resource policies that nonprofits tend to provide.

How long this process can continue before serious problems of employee turnover and burnout surface is anyone’s guess. What is more, the pressures of continued health insurance cost escalation are likely to accelerate the trend toward increased nonprofit fees and charges, undermining the sector’s ability to fulfill its mission of service to those in greatest need and its broader advocacy role. The “silent tax” represented by continued rapid increases in health insurance costs thus has particularly profound implications for the nation’s nonprofit sector, implications that have been largely overlooked until now. Hopefully, the data reported here will help focus new attention on the health insurance crisis facing nonprofit employers as well.

http://www.jhu.edu/listeningpost/news/pdf/comm03.pdf

Comment: Employees of nonprofit organizations usually accept lower levels of compensation, but do so graciously, acknowledging that the social good advanced has its own rewards. Unfortunately, these organizations are not exempt from the same health care cost pressures faced by for-profit corporations. But most nonprofit entities do not have as much budgetary flexibility. It is particularly disconcerting to see these organizations being forced to use the same methods as businesses in shifting health care costs to their hard-pressed employees.

We are already paying enough to provide comprehensive care for everyone. We
could fund our system much more equitably through a national health insurance program. Then nonprofit organizations would not be faced with the current, unacceptable alternatives of either shifting more health care costs to employees, or increasing fees to the needy being served. We can do better.

Two UW professors say U.S. could afford health care for all

Two UW professors say U.S. could afford health care for all
Administrative bloat blamed for driving up costs

Jesse Hirsch- Portage Daily Register

Criticizing the large amount of “myth and knee-jerk reaction” surrounding universal health care, Chairperson Meghan Yost invited two prominent and vocal health care advocates to this week’s meeting of the Columbia County Towns Association.

Drs. Gene and Linda Farley, professors emeritus at the UW Madison Medical School, gave a rousing presentation Monday night about remedying ills in the U.S. health care system.

Gene Farley, former chairman of the school’s Department of Family Medicine, started by praising the potential of this country’s health care.

“We have some of the most fabulous resources in the world,” he said. “It’s unfortunate we also have one of the most clobbered health care systems.”

Farley’s wife then listed the two biggest things that need to be removed to get health care where it needs to be — huge overhead and the “for-profit corporatization of medicine.”

”(Doctors) feel like professionals but they try to turn us into businesses,” Gene Farley said.

The Farleys showed statistics about the huge increase in clerical and administrative workers needed to deal with complicated insurance programs, claims and billing.

For instance, they said a 900-bed hospital in Toronto, Canada, where health care is universal, has about three or four workers in the billing department. At a comparably sized hospital in Boston, they said, there are well over 300 billing employees.

The Farleys believe it is this bureaucratic waste, combined with corporate greed, which is largely responsible for the “grossly inflated” cost of health care in America.

They said that redirecting the vast amount of money spent on health care and pooling it together could create adequate resources to take care of every uninsured American.

Linda Farley cited statistics that the United States spends more tax dollars on health care, between Medicare, Medicaid and insurance for public employees and veterans, than most countries with a single payer health care system.

“U.S. public spending on health care is more than any other first-world country and it only covers 45 percent of the population,” she said.

The Farleys believe a universal health care system would actually save money and cut down on red tape, rather than the reverse. And they think the time for change is now.

According to the U.S. Census Bureau, 45 million Americans lacked health insurance in 2003, 1.4 million more than in 2002 and 5.2 million more than in 2000. In Wisconsin, the number of uninsured hovers around 500,000.

Working on a state-by-state basis is the first step, according to Gene Farley. He said the current administration is unlikely to make significant progress in overhauling our troubled system, so change will have to happen at the state level.

Farley said $7.72 billion was spent in Wisconsin in 2003 on health care administration, but that over $5 billion could have been saved with a single payer system.

“We’ve got to get out there and let our legislators know this matters to us,” he said.

After Monday’s meeting, Harlan Baumgartner, chairman of the Otsego Town Board, said he agreed with many points the Farleys made, but that change is “an uphill battle.”

“We seem to be very embedded in the way things are right now,” Baumgartner said. “The problem is how we get past people’s unwillingness to change.”

As far as biases against universal health care, Baumgartner feels this is an unnecessary complication to an already bloated problem.

“There’s a lot of prejudice in people’s minds,” he said. “To me, this is just a problem that needs to be solved.”

Growth rate in health cost to employers slowed in '04

The New York Times
November 22, 2004
Growth Rate in Health Cost to Employers Slowed in ‘04
By Reed Abelson

After years of double-digit cost increases, the rate of growth in what employers pay for employee health insurance slowed significantly this year, according to an annual survey to be released today.

The average employer cost for health benefits for an employee rose 7.5 percent in 2004, to $6,679, the lowest increase since 1999 in a survey of about 3,000 employers by Mercer Human Resource Consulting.

But this slowing rate was largely the result of employers shifting more of the cost onto their employees and changing the kinds of plans they offer, said Barry Schilmeister, a senior health care consultant for Mercer.

“What we’ve seen for a couple of years running now is that employers have made very significant changes to their programs to cut three to four points off that inflation rate,” he said.

The overall growth in health care costs remains a concern, Mr.Schilmeister said. “Underneath it all, while general inflation is 2 percent, medical inflation continues to be 10-plus percent,” he said. “We still have a significant problem to deal with.”

http://www.nytimes.com/2004/11/22/business/22care.html

Comment: Rather than being good news for employers, this is terrible news for employees, and for the rest of us. Health care costs continue to increase, but those costs are being shifted from employers and insurers to individuals, especially those with greater health care needs. Having health insurance no longer means that you have protection against financial hardship in the event of significant medical need.

It’s not that we don’t have enough money. We have plenty. We are already spending enough to pay for comprehensive care for everyone. The problem is that we are slowly shifting away from the insurance principle wherein the many who are healthy contribute a modest amount to pay for the care of the few who are sick.

Up to the present, we have refused to enact policies that would address cost issues by reducing the profound waste in our system. At the same time we are adopting policies that will hold down the modest amounts contributed by the many who are healthy, that is, we are holding down premiums paid for coverage. This means that insurance will offer fewer benefits and will increase cost sharing. Thus, by default, we are making the few who are sick pay even greater amounts for their care.

Where is our social contract of solidarity? I guess we can cross that one off of our lists as we give thanks tomorrow. No sense wasting our “prayer capital” on that one.

November 23, 2004

Letter to the editor of NY Times on Single-Payer

New York Times
Health Care Costs
November 23, 2004
 
To the Editor:
 
Increasing incentives and competition are not magic potions to control health care costs (Economic Scene, Nov. 18).
 
Independent studies in a number of states have demonstrated that a single-payer system would cover everyone and eliminate the wasteful profits and administrative costs of the middlemen that plague our current system.

When large corporations begin to see a single-payer system as the means by which they can be relieved of providing health care for their employees and thereby be more globally competitive, the political imperative for Medicare for all will be overwhelming.

Gerald Gollin, M.D.
Redlands, Calif., Nov. 18, 2004

Access, Quality and Cost in the Era of Consumerism

California Medical Association
8th Annual Leadership Academy
Acceleration: Access, Quality and Cost in the Era of Consumerism.
La Quinta, California
November 18-21, 2004

Keynote Presentation

Can a “Consumer-Driven” Health Care System Succeed?

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

“What should be the goal of a health system? It should improve health status. It should protect families from financial ruin over illness. It should leave people satisfied with the care they got. But it should also make them feel good about a sense of fairness in their society, as Canadians fiercely feel proud of the sense of fairness in their system, whatever problems they have. And the Germans and the Swiss are fiercely proud of the social contract of solidarity.

“Intermediate goals are access to timely care, that feeds into health status and that. See, these are not goals, they’re just instruments to reach these goals: efficiency and fairness, fairness in financing health care…

“We don’t talk enough about financial protection, about people who have cancer also going broke, and the insult and hurt that that represents.

But, you know, ‘It wasn’t my fault that I got cancer, now I have to sell my house.’ That’s an insulting thing for a Canadian and German like me to think about. And it happens. Many, many American families go broke over health care.

“We don’t ever talk enough about fairness and equity, not at all about the social ethic. We talk about the Judeo-Christian ethic as if it were something else. It should really be ours, and, incidentally, there is a confusion in all kinds of other ethics. But they all ask for the same.

“In the present instance, I think we should ask how these goals are affected relative to the status quo and relative to alternative policy options that we might consider, like traditional, comprehensive coverage with managed care, single payer system, and so on. And I think we need to have some debate; which of these approaches actually gets us closer to those goals…

“A major problem in the U.S. is we never discuss ethics; that’s somehow a taboo topic, because here we get ideological and then we get political. And I say, ‘Bullshine.’That is at the core of health care. That is the foundation that should surround health care, because that’s how physicians,among others, are trained.

“So, to me, we can’t really judge whether this will succeed. Some people will say, ‘It succeeds.’ It’s like beauty and honor, the evaluation of consumer-directed health care will be driven much more by ideology than by data. And that’s where we are right now. And I wish it were more driven by two things: data, to tell us what this thing really does, and, secondly, what would we like to be like as a people.

“Do we want to be the kind of people that treats soldiers the way we do ($8000/year pension after losing a limb)? Do we want to be the kind of people that leaves a mother, who raises three children for America, sitting there without health insurance or (with only) the policy that she can find on eHealthInsurance.com (leaving her with $20,000 out of pocket on $26,000/year income)? Is that what we’re about as a people? I’m just an immigrant here. I can’t tell you. This is your problem, not mine. I’m well to do; I buy out of this. But I urge you to reflect on those aspects of it before we get into the technique.

“We can do this. When you tell me the ethics; we can implement it, or the people who spoke yesterday (see comment). We know how to do this. But ethics first. And I think we put ethics last.”

For tape or CD recordings of the Leadership Academy:
http://www.audio-digest.org/cgi-bin/htmlos/01203.1.1018082396615917308/cma

Comment: The first day of the plenary sessions began with speakers well known to those of us who have studied consumer-driven health care (CDHC). John Goodman of the National Center for Policy Analysis and Grace-Marie Turner and Greg Scandlen of The Galen Institute explained consumer-driven health care, especially health savings accounts and high-deductible health coverage. They did not present any new information on CDHC.

The plenary sessions closed with Uwe Reinhardt’s presentation. Mentioned here are only a few of his many important points. He questioned whether patients could be empowered decision makers since current information systems are too primitive to allow individuals to make truly informed decisions about their health care. He provided considerable data to demonstrate that current high-deductible policies leave low income individuals exposed to the potential of insurmountable medical debt. He demonstrated how health savings accounts reward higher income individuals with progressive tax benefits to the detriment of lower income individuals. He showed that those in the lower one-third of income levels will bear
the financial brunt of the CDHC model. Then he ended his presentation with the message transcribed above.

The majority of those attending represented the leadership of medical associations and health care providers. I would describe their response to the presentations on CDHC as mixed, at best. Yes, some passionate supporters were in the audience.

But there is great news. With this audience of physician leaders, Uwe Reinhardt was the only speaker to receive a standing ovation!

There is hope for the future of our health care system.

November 18, 2004

Controlling Health Care Costs

The New York Times
November 18, 2004
Controlling Health Care Costs
By Hal R. Varian

Health care just keeps getting more expensive.It has been argued, with considerable justification, that a significant part of the increase in health care expense is a result of improved quality.

Economists have two magic potions to control prices and improve quality :
competition and incentives.

What is needed is experimentation with, and competition among, different ways of delivering health care: prepaid group practices, health maintenance organizations, traditional preferred providers, and other ways not yet thought of. The key is to give consumers a choice among different delivery systems, not just minor variations on a single theme.

Current practices offer perverse incentives. Employers often cover some fixed fraction of the cost of each plan. (Stanford economist Alain C.) Enthoven… argues that it would be better to have the employer cover the entire cost of the low-price plan, and let the employees who choose higher-priced plans cover the additional costs themselves.

…it seems clear that more choice, more competition and stronger incentives would be good medicine for the health care industry.
http://www.nytimes.com/2004/11/18/business/18scene.html

Comment: Just in case you believe that we have moved the reform debate beyond failed models, we haven’t. But Enthoven and colleagues are still beating the drum for an experiment with competition amongst health care middlemen, integrated with delivery systems.

The fact that this article was published in the business section of The New York Times implies that the concept has some credibility. But California has completed an extensive and expensive period of experimentation with this model and it has failed miserable.

Admittedly, Enthoven claims that the experiment wasn’t valid because comprehensive, integrated systems were under-represented in the experiment. But even large urban areas would have difficulty corralling providers into enough truly integrated but completely separate systems to be able to provide multiple, readily accessible, comprehensive systems. He believes that part of the problem lies in the fact that most providers contracted with many loose networks, and they really couldn’t effectively compete against themselves. As an example, in his model, a major hospital would be a part of a single integrated system. Since hospitals must be accessible, how many hospitals can compete in one service area when patients are limited to the hospital that is a part of their integrated system? Enthoven’s refinement of the failed model of competing plans simply cannot work because of the logistical hurdles.

And if Berkeley professor Varian (the author) believes that the primary reason for the increase in health care costs is quality, he must have isolated himself from the great body of health policy literature. It is no wonder that he supports such a highly flawed model that has already failed experimentation in the marketplace. He missed the whole show.

The business community should be interested in a model that controls costs
,improves efficiency, provides better incentives for quality, and eliminates the benefit plan problem for employers. The health policy literature indicates that a single payer plan would accomplish those goals. You would think that the editors of the business section of The New York Times might want to publish such a concept in the interest of promoting an informed discourse on reform, especially reform that serves the interests of business.

Or shall we simply continue on the easier path of living with our political preference for perpetuating a system characterized by waste, inefficiency, mediocrity, and staggering costs in health care?

November 16, 2004

Flu shot shortage: Health care woes in a nutshell

By Ellen Goodman 
The Boston Globe, 11/15/04

BOSTON — Toward the end of the campaign, President Bush offered his small variation on JFK’s famous line: Ask not what your country can do for you, ask what you can not do for your country:
“My call to our fellow Americans is, if you’re healthy, if you’re younger, don’t get a flu shot this year.”

I have followed the patriotic edict to go unarmed into this flu season. In fact, unlike certain members of the Congress who shall remain nameless, I have no choice but to follow it. At the same time, I have been collecting various little anecdotes for the Flu Story 2004.

First is the tale of a New York friend who had to go to Toronto for work. She found the name of a doctor through the Canadian sister of a friend of a friend. Then, feeling vaguely like a mule in some illegal drug operation, she got her shot, wrapped the rest of the vial in ice and smuggled it back to her stateside doctor for distribution to seven high-risk patients.

There is another friend, a certified member of the greatest generation living in the capital of the free world, who ended up at 5:30 one morning in a drug-store line in search of a shot. Then there is a department store Santa, Nick Pallotto, 62,
of Denver, who couldn’t get the vaccine despite the fact that about 10,000 children will pass across his lap.

If we are lucky, if the flu season is mild and the crick don’t rise, this may not be a disaster. But for the moment, we have the Centers for Disease Control and Prevention rationing the last 10 million doses and we have New York City independently ordering its own vaccine.

In short, every American is getting a chance to see what life’s like for people without health care insurance and just how precarious the health care system really is. The strain of flu that is coming our way has been dubbed by one reporter as the Free Market Flu. This shortage is not, after all, a natural phenomenon, like say, a shortage in pomegranates or pineapples.

The entire debacle comes from the fact that preventing the flu isn’t as profitable as, say, treating erectile dysfunction.The major U.S. drug companies, who continuously tell us that their profits are for our benefit, don’t do flu anymore.
For some years, flu prevention has been outsourced without oversight. Chiron Corp., one of the vaccine manufacturers, had worried the FDA as long ago as 1999, but it was the Brits who blew the whistle on them in October when this year’s batch of vaccines was contaminated. We were left dependent — mon dieu! —
on a French company, Aventis Pasteur.

As James Morone, a political scientist and co-author of the upcoming “Healthy, Wealthy and Fair,” says, “When one company in England runs into trouble, the whole thing collapses. Private markets are as only as good as the public health system overseeing them. If there were a sudden run on watches or sofas it wouldn’t be a problem, but health care can’t work that way.”

Instead of sofas and watches, it might be life and death. About 36,000 people died from the flu last year and that was when vaccine was available. After Sept. 11 — with all the talk of bioterrorism, anthrax and smallpox — there was the beginning of a dialogue about strengthening the public health system. But today we rarely talk about the basics, such as vaccines, as a public good.

Americans have long been told that national health care would mean long lines, rationing and g second-class medicine. Despite spending more of our gross national product on health care than any other country, we rank 29th in life expectancy, right between Slovenia and Portugal. And what do we have? Long
lines and rationing. Not to mention lotteries, and a shot in the arm for Canadian tourism.

Maybe it takes the Free Market Flu to remind us that sometimes we need a public health system as much as we need a fire department or a military. For the moment, however, a casino in Las Vegas has generously donated its 5,000 doses to the local health department. A retirement home has given the Denver Santa his shot.

Meanwhile back home, I think I will tie a yellow ribbon around a great big pot of chicken soup.

Ellen Goodman (ellengoodman@globe.com) is an associate editor and columnist for The Boston Globe.

Memo on reform from a Medical Economics staff member

Medical Economics
November 5, 2004
Memo from the Staff

A crisis too loud to ignore
By Robert Lowes

I began writing this in a hotel bathroom in San Francisco. Only there could I escape the racket of a picket line 20 floors below and hear myself think: Maybe doctors shouldn’t view national health insurance as a dirty idea. I had a window on this war from my room at the Renaissance Parc 55. Its workers weren’t striking, but I could see picketers across the street at the Hilton. Some carried signs reading “Healthcare is a Right” while others drummed buckets, blew whistles, and chanted from 7 a.m. to 10 p.m., the limits set for noise-making. A renegade drummer woke me up at 2 a.m.

Earplugs courtesy of the hotel were useless. The din was unnerving but understandable. A proposed contract would increase a worker’s health in-insurance premium from $10 a month, an unbelievably low amount, to $273.42 a month in five years, an unbelievably high amount. That’s more than my premium, and I make more than they do.

Nationwide, millions of laid-off workers have lost insurance coverage. Millions more who’ve kept their jobs find it costlier. So what’s the systemic solution? “We don’t have national health insurance,” said Tim Miller, a waiter turned picket captain. “Shame on America.”

Maybe national health insurance strikes you as socialized medicine. But our society must replace the current system with something that’s fairer and more compassionate. I was heartened by the report of a surgeon who grabbed a
sign and joined the hotel strikers. If anybody has the moral authority to provide leadership on this issue, it’s the healing profession.

The presidential election is over, but the crisis remains. Whatever we do, we can’t succumb to the temptation to stick in earplugs. Otherwise, the drumming will only get louder.

http://www.memag.com/memag/article/articleDetail.jsp?id=130910

Comment: The message is familiar. What is notable is the source: Medical
Economics. The rationale of national health insurance has not escaped anyone. The anti-government ideologues are becoming more shrill in their response.
But the good news is that concerned individuals of sound mind across the political spectrum now agree that we must have comprehensive reform. And they realize that options other than national health insurance do fall short of our goal of affordable, comprehensive coverage for everyone.

The drumming is growing ever louder.

November 15, 2004

Honoring our troops

Berkshire Eagle, Lenox, MA
Monday, November 15, 2004
Honoring our troops
By Suzanne L. King M.D.

Last Week we celebrated Veterans’ Day. Parades and services honored veterans from past wars, even as American troops pushed forward against the Fallujah insurgency. Soldiers continue to die, and many more have been wounded as they fight in the current war in Iraq.

Meanwhile, a quiet and less publicized battle is being fought at home: the fight for health care by veterans of both the Vietnam and the Persian Gulf wars. A Harvard Medical School study recently reported that almost 1.7 million American veterans were uninsured in 2003. That means they did not have health insurance, and they were not able to receive care at Veterans Health Administration (VHA) hospitals or clinics.

The Bush administration halted VHA enrollment for middle income veterans last year if their yearly income was above $25,000. In addition, veterans who did qualify for VHA benefits often could not obtain VHA care because of waiting lists, unaffordable co-payments, or lack of access to VHA facilities. (Veterans of World War II and the Korean War are covered by Medicare because of their age, and therefore have access to America’s single payer health care system for the elderly).

Twelve percent of all veterans were uninsured in 2003. Younger veterans were least likely to have health insurance, with more than one-third of veterans under 25 years of age uninsured, and one in seven aged 25-44 years without insurance. Of course, their families did not have insurance coverage either. Many of these veterans have major health problems, often related to their war duty; less than a quarter indicated they were in excellent health.

On television last night, a grateful father talked of his son’s return home from Iraq, a son whose skull had been broken into 500 pieces, and who lay in a coma, hospitalized for five months. He is slowly recovering, and feels guilty that he is safe at home and his friends are still fighting and in danger. With courage and dedication, he has risked his life for his country; will his health care needs be forgotten 10 years from now?

The Berkshire Eagle recently published an article about the thousands of Gulf War veterans who have been ill with a mysterious syndrome that includes chronic fatigue, dizziness, loss of muscle control and balance, memory problems, and gastrointestinal symptoms. Originally attributed to “stress,” current VA studies are focussing on the possibility the symptoms are secondary to neurotoxins like pesticides or nerve gases used in the war. Thirteen years later, these veterans are still having symptoms related to their war experience. They have sacrificed their health; how can we not provide health care for all of them?

Uninsured veterans are not nursing their wounds; 86 percent of them worked
within the last year. They had as much trouble getting medical care as other uninsured people, most of whom are also employed. Dr. David Himmelstein, a professor at Harvard Medical School and an author of the study, commented, “This administration professes great concern for veterans, but it’s all talk and no action. Since President Bush took office the number of uninsured vets has skyrocketed, and he’s cut VA eligibility, barring hundreds of thousands of veterans from care. Our president has put troops in harm’s way overseas and abandons them and their families once they get home.”

What is the solution for these uninsured veterans? It’s the same solution that everyone in our country, including 45 million uninsured Americans, needs: a universal single payer national health insurance program, funded and administered by the government (i.e., Medicare for everyone). How can we ask our soldiers to risk their lives, lose limbs, develop chronic illnesses, suffer post-traumatic stress disorders, and then not care for them when they return home? And how can we not provide health care for every citizen of the United States, a country founded to provide “life, liberty and the pursuit of happiness” for everyone? Other industrialized countries, all of whom have national health insurance, manage to provide universal health care at half the cost we pay for health care per person. The problems of rising health care costs and lack of
access to health care in America cannot be solved by incremental change and
continued reliance on market-based strategies. We need to change the system
itself. We need universal single payer health care. Then we can truly honor
our troops.

November 14, 2004

Greetings From The Disunited “United States Of Canada”

November 14, 2004
WASHINGTON — I pledge allegiance to the flag of the disunited states of America.

Now is the winter of some people’s discontent following the stormy election of President Bush. The Internet is all abuzz with residue resentment. Canada’s immigration Web site reports a sharp increase in inquiries from Americans seeking information on how they can defect to our chilly neighbor. Other Webheads are offering a “Boycott Ohio” petition.

That in particular saddens me, since I grew up in Ohio and still have friends and relatives living behind the Buckeye curtain.

But the wackiest idea I have run across so far is the option offered by Web sites that are calling for secession.

That’s right. Secession, you may recall, didn’t work out very well the last time it was tried in this country. (For the benefit of those of you who snoozed through history class, I point out that secession resulted in the Civil War.)

Nevertheless, several Web sites are offering color maps of a new North American political landscape in which the so-called “blue states” that voted for Democratic Sen. John Kerry are joined to our northerly neighbor in a new, blue country called the “United States of Canada.”

The remaining states—the “red states” that voted for Bush—are renamed “Jesusland,” which sounds like a good name for some televangelist’s Christian amusement park.

Well, count me out.

I think the best revenge for blue-state Americans is to continue to stand with our red-state brothers and sisters to hold Washington accountable, no matter which party happens to be in charge.

Besides, as much as I like to visit Canada, I don’t see much advantage to having Canada permanently visit me—except maybe national health insurance.

That’s not a small thing. As you may have heard Kerry mention repeatedly during the recent presidential campaign, an estimated 45 million Americans in this, the world’s most powerful and prosperous country, lack health insurance.

Back in the early 1990s, only about 30 million Americans lacked health insurance and President Bill Clinton and First Lady Hillary Clinton took a stab at trying to close that gap.

Their push for universal coverage was beaten back quite impressively by the health insurance industry’s “Harry and Louise” ads.

Those scary little attack ads painted horror scenarios of skyrocketing costs, shrinking coverage and Americans no longer able to choose their own doctors.

A decade later? Surprise, surprise. We have the higher costs and shrinking coverage that “Harry and Louise” warned us about, except that we also have even more uninsured patients.

Now the same insurance industry tells us scary stories about Canadians rushing to the U.S. for elective surgery and other procedures they can’t get quickly enough in Canada. You have to turn to the news to hear the other side of that story, like the Americans now turning to Canada to get their flu shots or to find cheaper prices for American-made pharmaceuticals.

And you also might hear in the news about how Americans are more dissatisfied than citizens of other major industrial nations with their basic health care even while paying more of their own money for treatment, according to a recent five-nation survey by the non-profit Commonwealth Fund.

One-third of Americans told the pollsters that the U.S. health-care system should be completely rebuilt, which was far more than residents of Australia, Canada, New Zealand, or the United Kingdom. Just 16 percent of Americans said that the U.S. health-care system needs only minor changes, the lowest number expressing approval among the countries surveyed.

Want to see President Bush’s plan for insuring the uninsured? Hold up a blank sheet of paper.

Well, OK, it’s not quite that bad, but it’s close. He has offered tax-free health savings accounts for those who can afford to put money aside for their health-care costs. The business-oriented Bush seems never to have witnessed a social problem that cannot be solved with a tax break.

But what if you’re a minimum-wage waitress with kids, and you can’t afford to put money aside for health-care costs? Well, I guess there’s always prayer.

Of course, no country’s health-care system is perfect, and America does offer the best health care that money can buy, if you can afford it. The problems come when you can’t afford it.

We’re problem solvers. That’s the American way. We can build a better system, if we want to. The first step is to demand what we have not had, a fair and balanced national health-care debate, not just dueling campaign ads.

Headaches For All

Everybody knows it will take a lot more than diet and exercise to fix America’s health

AMERICANS are constantly told that their health care is the best in the world. In terms of research, technology and advances in surgery, the boast is undoubtedly true. In other ways, it is hard to justify. At any one time, more than 43m Americans under the age of 65 have no health insurance (the elderly are covered by Medicare, a federal insurance programme). The infant mortality rate for black Americans runs at 14 per 1,000 live births, double the rate for white Americans and over four times the rate in Japan. Indeed, in a 2000 study of the effectiveness of health-care systems around the world, the World Health Organisation ranked America only 37th (France came top).

If all that speaks ill of the nation as a whole—over half of America’s uninsured in 2002-03 were without cover for at least nine months—the situation in some states is far worse. Families USA, a health-consumer organisation, notes that in Texas—the state that George Bush likes to call home—some 43.4% of the “non-elderly” population were without health insurance for all or part of 2002 and 2003. In California the rate was 37.1%; in Florida 34.6%. The Kaiser Family Foundation (KFF) notes that infant-death rates across the South, from Arkansas to the Carolinas, are far higher than in the western states.

This is a poor reward for spending more on health than any other country. Health care accounts for almost 15% of America’s gross domestic product, compared with less than 8% for Japan and Britain. Moreover, where other countries pay for their health care mostly out of taxation (the OECD average in 2001 was 72%), over half of America’s spending is accounted for by private insurance—normally provided by an employer—and out-of-pocket payments. Indeed,America is the only industrialised democracy without publicly funded universal health cover.

To counteract the costs of medical advances and malpractice suits,insurance premiums have been rising by more than 10% a year. In 1998 the average health-care cost per employee for a private-sector company was $1 an hour; by last year, it had risen to $1.50. This has a perverse effect: employers either tend to cut or eliminate their workers’ coverage—thereby adding to the uninsured—or try not to hire new workers. With the cost of insuring a single worker now running at around $3,000 a year, the proportion of workers covered by a company health plan has fallen to 61% in 2004, according to KFF, compared with around 65% in 2001.

The Search For A Cure
Clearly, reform is needed. One reason is pressure from voters. Health care is consistently near the top of their concerns, especially if they are old; old people are both sicker, and vote more, than the average American. They note that many of their drugs are much cheaper in Canada than in the United States, and ask why the federal authorities are refusing to legalise imports from across the northern border. (In defiance of the Food and Drug Administration, Illinois has recently approved the importation of drugs from Canada; Vermont is suing the
FDA.) Seizing the moment, John Kerry says he backs such imports.

A second reason for reform is the inexorable pressure of demography. As baby-boomers retire, they will add to the burden of health care in general and Medicare in particular. Indeed, America’s total expenditure on health care is expected to rise from just under $2 trillion a year now to almost $3 trillion by the end of the decade.

So the question is not so much whether to reform, but how. The Clinton plan a decade ago for universal coverage was defeated by doctors and insurance companies, as well as by Republicans. In its place came health-maintenance organisations (HMOs), health-care-management companies that contract with doctors and hospitals to manage treatment and costs. The proportion of employees with employer-provided care enrolled in managed health-care plans rose from 27% in 1988 to 92% in 2000.

But HMOs succeeded only for a time in slowing the rise in health-care costs. Some politicians, such as the former Democratic presidential candidate, Dennis Kucinich, believe the only workable solution is to replace the private-sector insurance companies with a government-run “single-payer” system, as in Canada. This, however, would guarantee the same lobbying that defeated Mr Clinton—which is why neither Mr Kerry nor Mr Bush is talking about dramatic change.

Mr Bush’s remedy is particularly modest. He proposes extending the new Health Savings Accounts to allow individuals to deduct from their taxes the cost of premiums for major medical coverage. According to the Treasury Department, this would extend insurance to an extra 1m Americans. Similarly, there are tax credits to help workers laid off “due to international trade” to find insurance; other credits would make insurance affordable for around 4.5m workers with no employer-provided or public insurance. Meanwhile, a five-year plan is already under way to fund 1,200 new or expanded community health centres to serve an additional 6.1m people, and association Health Plans are proposed to allow small businesses to band together to provide cover to another 600,000.

The centrepiece of the president’s reform, however, is to make prescription drugs available to the 40m elderly and disabled Americans covered by Medicare. From 2006 (a discount card will in the meantime offer savings off retail prices), a Medicare recipient will pay the first $250 in a year, Medicare most of the next $2,000 and the recipient the next $2,850 (after which Medicare will again pick up the tab). The plan is both complicated and expensive: over $570 billion, according to the latest estimates, over ten years. Embarrassingly for the president, the price tab is rising not just for the government but also for Medicare recipients: their premiums are set to rise by 17% in 2005.

These are not the only problems with Mr Bush’s proposals. The tax credits, aimed at helping the poor and worth some $90.5 billion over ten years, would actually benefit the rich, who need no help, and would be little help to the low-paid, who pay little or no tax and are most at risk of losing insurance. As for Medicare reform, the congressional Budget Office reckons that, as an unintended side-effect, a third of retired people whose drugs are now covered by their former employers will lose that coverage (why should the bosses pay if the government will pick up the tab?) and be forced to accept inferior cover from Medicare. The most damning criticism of the proposals, however, is that their impact will be too limited: according to the Kaiser Family Foundation, the ranks of the uninsured will fall by just 1.8m.

THE 95% SOLUTION
By contrast, Mr Kerry aims to reduce the number of uninsured by 26.7m and so bring health insurance to 95% of America’s population. That ambition carries a hefty price-tag of $653 billion over nine years, which a President Kerry would finance mainly by repealing Mr Bush’s tax cuts for Americans earning over $200,000. In the Kerry vision, all Americans would have the right to the same health plans as their congressmen and some 9m federal employees and their dependents. Tax credits would help find cover for 55-64-year-olds, who are too old to be good insurance risks for an employer but too young to qualify for Medicare. To help poor families, Mr Kerry would make the government assume all the costs of the 20m children who now benefit from state Medicaid plans. In return, the states would have to expand insurance to those poor families who do not qualify for Medicaid.

Mr Kerry’s biggest claim is that he can cut insurance costs by up to two-thirds for small businesses: the federal government would act as a reinsurer, reimbursing employee health plans for 75% of costs above $50,000. This alone would lower employee premiums by 10%. In addition, there would be tax credits of up to 50% of the cost of covering employees, and employers would profit from buying into the federal worker-insurance programme. Meanwhile, everyone—firms, employees and states—would benefit from discounts gained by the bulk purchasing of drugs. (At the moment, the drug companies are loth to co-operate with any buyer except Medicaid, the federal/state programme for the poor.)

Add in a “quality bonus” to give hospitals a financial incentive to reduce medical errors; add, too, a “technology bonus” to favour computerisation and so cut non-medical costs (now running at $350 billion a year) from $12-25 per health-care transaction to less than a cent. The result is a health plan which the 35m-strong AARP, the formidable lobby group for the elderly—which supported Mr Bush’s Medicare scheme—finds much more convincing than the president’s.

That does not mean it is without problems. Mr Bush’s team notes that while Mr Kerry claims it will be harder to bring undeserving malpractice suits, he refuses to cap the awards—even though the Bush camp says that the “broken medical liability system” drives up costs by at least $28 billion a year for the federal government alone. (It certainly pushes up the cost of doctors’ malpractice insurance.)

The Bush team also attacks Mr Kerry for adding to the burden of regulation. Small businesses would have to offer costly benefits in order to join the federal employees’ health-benefits programme. Overall, say the Republicans, the Kerry plan simply shifts the burden to the taxpayer. But given the unpopularity of the present system, this is a burden that taxpayers sometimes seem ready to bear.

AMA members' opinions on reform

American Medical Association
Division of Market Research and Analysis
September 2004

2004 AMA Advocacy Agenda Setting Survey
(The survey was sent to all 202,777 members of the AMA. 8,323
responded, either by mail or online.)

Members’ Opinions of Approaches to Increase Health Insurance Coverage to the
Uninsured % Favor
(The first number is the percent of physicians in favor, and the second is the percent of medical students and resident physicians in favor. Multiple responses are possible.)

53/50 - Use of tax credits
38/49 - Expanding eligibility for public programs
41/40 - National single payer system
24/34 - Employer mandates
27/26 - Individual mandates
53/44 - Government-sponsored catastrophic coverage

Office-based physicians (56%) are more likely than administrative physicians
(49%), hospital-based physicians (45%), and physicians in medical teaching/
research (45%) to favor the use of tax credits. Psychiatrists (58%) are the
most likely and anesthesiologists (30%) are the least likely of all specialties to favor a national single payer system. Physicians in medical teaching/ research (57%), administrative physicians (52%) and hospital-based physicians (49%) are more likely than office based physicians (38%) to favor a national single payer system. Physicians 40 years of age or more (43%) are more likely than physicians less than 40 years of age (35%) to favor a national single payer system.

http://www.ama-assn.org/ama1/x-ama/upload/mm/363/agendasurvhighlights.pdf

Comment: The AMA’s conclusion: “AMA members are divided on the approaches
they favor to increase health insurance coverage to the uninsured.” That is true. But some aspects of this survey are worthy of comment.

Many physicians with progressive views have dropped out of the AMA, partly
because of a perception that it is controlled by relatively conservative physicians. There is some basis for this perception as is exemplified by the fact that 75% of AMA PAC contributions for the recent election went to Republican candidates. Also, the health reform policies supported by the AMA House of Delegates are very similar to those supported by President Bush. So the survey likely is heighted toward the conservative physicians in the United States.

It has been said that there are three primary models of universal coverage:
universal single payer, an employer mandate with a backup public program,
and an individual mandate with a backup public program. It is quite remarkable that, of these three choices, a national single payer system has the strongest support. There is even greater support for government-sponsored catastrophic coverage, which would have some features of the single payer model, albeit with a high deductible requirement.

Tax credits received high support, but they are not insurance models. They are
merely a mechanism of funding insurance.

The employer mandate and individual mandate leave in place our current private insurance programs. They have the least support in this survey. All other options involve government funding and government administration, and all of them received greater support from the physicians responding.

It may be a stretch to say that the conservative physicians of our nation prefer a government-run, taxpayer-financed health insurance program. But it’s not far from the truth.

The AMA and PNHP should sit down together and discuss health policy, devoid
of partisanship. We may not be as far apart as it would otherwise seem.

November 12, 2004

Vets return, but not always with healthcare

Vets return, but not always with healthcare
Alexandra Marks Staff writer of The Christian Science Monitor
11/10/2004

After serving 410 days in Iraq with the 1st Armored Division, Spc.Stuart Wilf came home to Colorado on Oct. 2. He changed his clothes, borrowed his mother’s car, and went out with friends to celebrate. On the way home, he fell asleep at the wheel and had a head-on collision with a tree. He survived, but since he was newly discharged, he had no health insurance.

“That was a mind-boggling thing to find out the first day he’s out of the service,” says his mother, Becky Wilf. “His bill was $54,000 just for the hospital. That doesn’t include the surgeon.”

Specialist Wilf is just one of thousands of veterans returning home from Iraq and Afghanistan who advocates contend are falling through the cracks of a federal system unprepared to deal with so many soldiers. After spending months in a war zone, many of the 170,000 soldiers who’ve returned home are struggling with their transition to back to civilian life - from coping with a maze of red tape and contradictory messages on healthcare to finding affordable housing and jobs with adequate incomes to accessing disability payments.

One of the biggest problems, according to advocates and a report by the Government Accountability Office, is a lack of resources to deal with battle fatigue, or posttraumatic stress disorder, as it’s now called. Another is providing support for Reserve and National Guard troops, who make up 45 percent of the troops in Iraq.

“The bottom line is that the VA [Department of Veterans Affairs] wasn’t prepared for the 33,000 troops that have come back and gone to the VA needing care,” says Paul Rieckhoff of Operation Truth, a nonprofit advocacy group for veterans of Iraq and Afghanistan. “They’re definitely not ready for the flood that’s going to come back next year.”

View from the other side
The VA disputes that and says it has ordered its services so that returning veterans will receive top-priority care. Last year, it announced that it would no longer be able to provide health services to veterans who make more than $26,000 a year (on average) and have no service-connected health problems. As a result, VA spokeswoman Cynthia Church says that what were once “unbelievable wait times” have been reduced. That allows the VA to treat returning combat veterans who were wounded or have service-related problems for free for two years.

“No veteran now waits longer than 30 days for their first appointment,” she says. “In terms of access to facilities, we’ve got more than 158 hospitals and more than 800 clinics, and we contract with service providers in communities where there may be a need.”

The VA’s policy are less clear when it comes to vets like Wilf, who sustained injuries after he was discharged. He and his family spoke with four different VA representatives and were told that because his injuries were not combat related, he was ineligible for VA care.

After inquiries from reporters, the VA in Washington said that if Wilf had been enrolled in the VA system, he would have been eligible for treatment for noncombat problems because he had just returned from combat duty. But he would have to pay for a percentage of the cost if he were able, and he would not be a priority case. “Part of the problem is the way the law reads. It says it’s mandatory to provide care for a condition possibly related to service, but doesn’t really address treatment of an unrelated condition,” says Gary Baker, head of the Eligibility Center at the VA.

Wilf has since filled out the application to enroll but is still waiting for it to be processed. In the meantime, the hospital where he was treated has forgiven most of the $54,000 bill because he was technically indigent. But he still has another $24,000 in related bills to pay.

Wilf was active duty, but some returning troops in the National Guard and Reserves have also found themselves without healthcare. When they were activated, they were eligible for Tricare, the Defense Department’s health-insurance program, but they lost coverage when they returned home.

Last summer, however, Congress voted to extend Tricare coverage for 180 days after deactivation. And last month, it voted to extend the coverage again, this time allowing Guard and Reserve troops to receive a year of Tricare coverage for every 90 consecutive days they serve.

Mr. Rieckhoff of Operation Truth lauds Congress for the move, but he contends it’s still not enough. He points to his own situation. He was on active duty and served as an infantry platoon leader in central Baghdad for 11 months. But now he finds himself in a job with no insurance. He was also told that the VA would treat only service-related injuries.

“The ironic part is that I’m drilling in the National Guard. It’s not like I’m completely out of the military,” he says.

Harvard’s numbers

A study done at Harvard University has found that almost 1.7 million veterans of all wars lack health insurance, an increase of 13 percent since 2000. More than one in three vets under the age of 25, like Wilf, have no health insurance. “It’s particularly offensive to send people off to war and not take care of them when they come home,” says Dr. Steffie Woolhandler, a professor at Harvard Medical School and coauthor of the study.

The VA contends the number of veterans without healthcare coverage is far smaller. Ms. Church says 60 percent of those uninsured veterans would be eligible for care if they enrolled in the VA. The study’s authors dispute that, noting that many have incomes higher than $26,000, live in areas where there are no VA services, or were unable to receive care due to long waiting lists. Church charges that the study’s authors are using the issue of uninsured vets to further a political agenda of creating a national health-insurance system. Veteran activists discount that. “This is not a political issue; it’s a soldier issue,” says Steve Robinson of the National Gulf War Resource Center.

A Gulf War veteran, he retired from active duty in October 2001, applied for benefits in 2002, and has yet to be enrolled in the VA healthcare system. “What happens in Washington is that these important things get turned into political footballs to get kicked around,” he says. “Then the issue doesn’t get the attention it deserves.”
© Copyright 2004 The Christian Science Monitor.  All rights reserved.

A primer on health care

A primer on health care
In the first of a two-part series on the Japanese health insurance system, Tomoko Furukawa goes back to basics
By TOMOKO FURUKAWA
There are two main types of Japanese Health Insurance: National Health Insurance and Employees’ Health Insurance

Once you have joined the health insurance system, you will be issued with an insurance card (“hokensho”), which you must bring with you every time you pay a visit to a clinic or hospital or other medical facility. If you forget your card, you may have to pay the full amount for treatment, though this is refunded later.

National Health Insurance
All residents of Japan who are planning to stay in the country for at least one year and haven’t joined another health insurance program are entitled, and expected, to join the National Health Insurance Program.

This includes part-time workers, the self-employed, and those without full-time status at a company they work for (this often includes teachers at English schools).

Under this system, both the policy holder and dependents enjoy equal coverage.

The amount you must pay into the National Health Insurance System is based on local resident tax (which, in turn, is based on income), your assets, the number of people benefiting from coverage and, often, the number of people living in your area that have joined the system (eg. ward, city, town etc.).

At present, regardless of income and assets, the highest amount payable annually is 530,000 yen, though this can rise to 610,000 yen depending on the number of people over age 40 in your household. Payments are not automatically deducted from wages, but must be paid in installments at a post office or health insurance office.

Foreign residents are often shocked when they see a massive jump in their premium from the first year of joining the system to the next.

The reason for this jump is that, for the first year, the premium is set at a minimum of around 2,500 yen.

For the second year, however, it is calculated based on income.

Under National Health Insurance, the policy holder and his/her dependents must pay 30 percent of inpatient and outpatient fees, with 70 percent covered by insurance.

Those enrolled in all health insurance schemes can avail of some free or very low-costs general check-ups (chest X-ray, urinalysis, blood test etc.). Also available are dental checks (for cavities, gum disease etc.), TB tests and treatment if sick.

Health exams and check-ups are generally not covered by insurance. Local authorities and companies arrange yearly or twice-yearly check-ups at designated times for local residents and employees.

However, while a preventative check-up may not be covered, there’s nothing stopping the insured person from going to their doctor with a complaint (fictitious or otherwise) and having a check-up performed as part of diagnostic treatment.

The NHI reimburses amounts paid over 63,000 yen (35,400 yen for low-income families) for medical treatment in one month; amounts over 37,200 yen, starting from the fourth time, if a household receives high-cost medical care four or more times a year; amounts over 10,000 yen for treating long-term, government designated ailments such as diabetes. A list of these designated diseases and conditions is available from your local city/town office.

However, reimbursement details under national health insurance are decided by local governments, so specific details of benefits should be checked with your local insurance office.

You may also be reimbursed if you receive treatment at a facility that does not accept your insurance and consequently hits you with a hefty bill.

In order to qualify for the above, you must be able to show that you were forced, through an emergency or unavoidable situation, to go to that facility. However, applicants will not necessarily be reimbursed the full amount, but rather will receive repayment based on a government-fixed fee.

If you get prior permission from your local EHI office, you can be reimbursed for transportation costs to hospital.

The Japanese health insurance system does not cover costs incurred as a result of accident caused by a third-party, since in Japanese custom the third-party is expected to pay. However, if that person cannot pay, then the insurance system may reimburse your costs and bill the person involved themselves.

If you cause the accident you have no coverage under the health insurance system.

Employees Health Insurance

This plan is for company employees and their dependents. It covers those who work full-time or at least 3/4 of the hours that a full-time worker puts in for a company that has joined an EHI plan.

In order for your dependents (basically your extended family stretching back three generations) to benefit from your policy, they must rely on you for more than half of their livelihoods and have an annual income of less than half of yours — or up to 1,200,000 yen per annum.

Under the national pension plan, employer and employee each pay half the premium, which is based on a percentage of income.

Unlike the national health insurance system, the EHI policyholder pays 10 percent of costs, while dependents pay 20 percent of inpatient care costs, and 30 percent of outpatient costs.

For high-cost medical care, the EHI will reimburse any high-cost medical expenses or extraordinary medical expenses along the same lines as National Health Insurance.

Reimbursement usually occurs within two months of payment, though interest-free loans are available for those in need of funds to tide them over until the cash arrives.

Benefits are the same as those under NHI with the exception of coverage amount.

Getting out

It is essentially impossible to leave the Japanese health insurance system once you have joined, unless you are leaving the country, moving somewhere else, or starting a new job.

If you move jobs and go from full-time to part-time status you may decide to opt out of the health insurance system altogether and get private health insurance.

If you shift from EHI to NHI, you will be charged from the date you left the EHI.

You can receive an exemption from paying premiums if you have trouble paying due to unemployment, bankruptcy issues etc.

Health resources

There are several good resources for information on health insurance and health care in general in Japan.

One of the best is the Japan Health Handbook, published by Kodansha.

The book contains sections ranging from alternative medicine and mental health to old-age care, with lots more in between. Though Kodansha no longer prints the book, it may be still possible to find copies in English-language bookstores in major Japanese cities, and the book can certainly be found on Amazon and other online book retailers.

On the Web, many embassy homepages provide information on English-speaking hospitals and clinics around Japan. One particularly comprehensive list can be found on the homepage of the U.S. Embassy in Japan at japan.usembassy.gov/e/acs/tacs-7119.htm

Another good resource is the AMDA International Mediscal Information Center homepage ( homepage3.nifty.com/amdack)

This provides telephone services to foreign residents in eight languages, explaining the health care system in Japan to foreign residents and pointing them in the direction of medical facilities with staff who speak their language.

What’s not covered

Not covered under the two systems are normal childbirth; abortion for economic reasons; vaccinations; cosmetic surgery; orthodontics; alternative medicine. Also not covered are accidents that occur in or on the way to work.

Health resources

There are several good resources for information on health insurance and health care in general in Japan.

One of the best is the Japan Health Handbook, published by Kodansha.

The book contains sections ranging from alternative medicine and mental health to old-age care, with lots more in between. Though Kodansha no longer prints the book, it may be still possible to find copies in English-language bookstores in major Japanese cities, and the book can certainly be found on Amazon and other online book retailers.

On the Web, many embassy homepages provide information on English-speaking hospitals and clinics around Japan. One particularly comprehensive list can be found on the homepage of the U.S. Embassy in Japan at japan.usembassy.gov/e/acs/tacs-7119.htm

Another good resource is the AMDA International Mediscal Information Center homepage ( homepage3.nifty.com/amdack)

This provides telephone services to foreign residents in eight languages, explaining the health care system in Japan to foreign residents and pointing them in the direction of medical facilities with staff who speak their language.

Next week’s column will cover the above issues, aswell as those of tax deductions, coverage, high medical expenses, specialist treatment, back payments and more.

Send your questions and views, good and bad, on the Japanese health care system to community@japantimes.co.jp

The Japan Times: Nov. 9, 2004

Care for veterans

Lexington Herald-Leader Lexington, KY
Editorial, November 11, 2004

Care for veterans
Honor them by providing health services

When a group of Harvard Medical School researchers reported last month that almost 1.7 million military veterans have no health coverage, a spokeswoman for the Bush administration disputed the study.

She said fewer than 900,000 veterans lack health coverage or care. Either way, there’s no way to feel good about so many veterans going without health care, especially on this Veterans Day when war casualties are mounting in Iraq.

The physicians who produced the study are proponents of a single-payer national health care system and were accused by a Department of Veterans Affairs spokeswoman of using veterans to advance their agenda. Whatever their motives, they drew their findings from two government studies— the Current Population Survey and the National Health Interview Survey — that interview large random samples of the U.S. population.

For analysis purposes, they counted a veteran who had no health insurance but had been seen at a VA hospital or clinic as insured. Among the study’s
findings:
Uninsured veterans have increased by 235,259 since 2000 to 1,694,312. The typical uninsured veteran was an employed man in his late 40s with one or two family members.More than two-thirds were employed, and 7 percent worked more than one job.

Many uninsured vets had major health problems, and a disturbingly high number reported problems in obtaining health care. Two-thirds reported receiving no preventive care the previous year.

Almost all World War II and Korean War vets are old enough to have medicare coverage. But 1 in 11 of the 7.85 million Vietnam-era vets have no health coverage. Among the 8.7 million veterans who served in other eras, including the Persian Gulf War, 1 in 8 are uninsured.

3.9 million members of veterans households lack health coverage. About half of uninsured veterans have incomes that disqualify them from VA health care under means-tests issued by the Bush administration last year for veterans with no service-related injuries.

The authors say the VA lacks resources to care for an influx of 1.7 million uninsured vets. They also said that in terms of access to care, uninsured vets are indistinguishable from the 45 million Americans with no insurance. Five million Americans lost health insurance over the last four years.

Nov. 11 is the day we set aside each year to honor those who gave part of their lives to defending our nation in the armed services. A good many of them, it seems, are on their own the other 364 days.

Urge NIH to provide public access to research

Action Required By November 16, 2004!

Following is a very important communication from Nobel Laureate Harold Varmus and his colleagues. The National Institutes of Health (NIH) has issued a policy recommendation that would ensure that the results of NIH-funded research would be available to all at no cost. This important policy would make sure that taxpayer-funded research would serve the public good. The comment period ends November 16. Please read the following, check the links, and then
Post Your Comments At The Link Provided.

This is a rare opportunity. Your simple act can make a difference. Do it now.

Thanks,
Don McCanne

*************

Dear Open Access Supporter,

On September 3, 2004 the NIH posted for comment an “Enhanced Public Access Policy.” This policy would require the recipients of NIH research grants to provide to the National Library of Medicine a digital copy of the final accepted manuscript (or the published version itself) of every published report resulting from NIH-funded research, so that the research results can be made freely available to scientists and the public through PubMed Central within six months of publication.

We are writing now to urge you to submit a comment in support of this proposal right away. The deadline for comments is just a few days away -November 16th.

The text of the proposal is available at:
http://grants.nih.gov/grants/guide/notice-files/NOT-OD-04-064.html
You can post comments here:
http://grants.nih.gov/grants/guide/public_access/add.htm

A powerful lobby of publishers and scientific societies is trying to block this plan. They claim that this is an unwarranted government intrusion on their business practices. In fact, the NIH policy has no authority over publishers - its rules apply only to the scientists who voluntarily accept grants from the NIH. The publishers remain free to operate their businesses as they always have and to compete in the free market to provide the best service and value to their authors and readers. But the publishers are wrong in arguing that they are entitled to monopoly control over access to the results of research that American taxpayers have paid for. On the contrary, the taxpayers who fund the research, and the scientists who carry it out, have every right to ask the grant recipients to provide open access to the published results. And they have every right to expect that the benefits of the research will be amplified by making it freely and widely available for others to use and to build on.

Let the NIH know that you support this policy proposal. Even better would be to tell the NIH that you would prefer an even stronger policy that requires full and immediate open access to all papers resulting from NIH-funded research. It is important that the NIH and other policymakers understand that this is not (as some publishers would have them believe) a radical proposal destined to destroy scientific publishing, but a thoughtful compromise that balances the desire for better access with the commercial interests of scientific publishers.

More information about the policy is available at:
http://www.nih.gov/about/publicaccess/index.htm
http://www.taxpayeraccess.org/

Notable statements of support for the plan include:
An open letter to the US Congress signed by 25 Nobel Laureates:
http://www.taxpayeraccess.org/bof.html
The Council of the National Academy of Sciences:
http://www4.nationalacademies.org/news.nsf/isbn/s09162004?OpenDocument

Please let us know if you have any questions.
Harold Varmus
Patrick Brown
Michael Eisen

AARP continues its attack on social insurance

The New York Times
November 12, 2004
AARP Opposes Bush Plan to Replace Social Security With Private Accounts
By Robert Pear

Gearing up for battle over the future of Social Security, AARP, the influential lobby for older Americans, said Thursday that it opposed President Bush’s plan to divert some payroll taxes into private retirement accounts. But it supports new incentives for private accounts that supplement Social Security.

Working closely with Congress and the White House, AARP helped shape legislation adding drug benefits to Medicare last year. Social Security is an even bigger issue, politically and financially…

Marie F. Smith, president of the organization, said, “AARP adamantly opposes replacing any part of Social Security with individual accounts.” But Ms.Smith added that the group supported incentives for people to establish personal retirement accounts in addition to Social Security.

John C. Rother, the organization’s policy director, said, “We favor private accounts when they are in addition to Social Security, but not as a substitute.”

http://www.nytimes.com/2004/11/12/politics/12benefit.html?oref=login

Comment: The single payer model of health care reform is a program of social insurance. Social Security and Medicare are our two existing programs of social insurance. An attack on either of them is an attack on the fundamental concept of social solidarity. Do we care about each other,or are we each on our own? AARP is certainly sensitive to the hit that it took after its highly publicized efforts to assist the Bush administration and the conservatives in Congress in crafting and passing legislation that threatens the Medicare program with privatization schemes. AARP didn’t want to entangle itself in a similar controversy with Social Security.

To ward off any criticism, AARP took the precaution of announcing that they are opposed President Bush’s plan to divert some payroll taxes into private retirement accounts. But does that keep them out of the fray? In the same announcement they state that they support personal retirement accounts in addition to Social Security. That certainly sounds like a wise position. But is it?

As you are well aware, many versions of private accounts already exist.There is a very real risk that another new version that is designed and marketed specifically as an extension of Social Security would be regressively funded. The affluent, the sector with the real political voice, would then advocate for a reduction in the funding of the existing program,or, at a minimum, strongly oppose the increased funding that will be required to support a program that becomes top-heavy in the ratio of retirees to workers.

If AARP truly believed that the interests of all seniors would be served best by delegating more funds to retirement pensions, then they should be supporting the much more equitable method of increasing funding of our existing Social Security program. In sharp contrast, regressive funding of private accounts is highly inequitable.

In supporting private accounts, AARP is stepping up to the negotiating tables having already wasted a major negotiating chip. That is a very fundamental violation of the game-plan rules of negotiation strategy.

We could sound like demagogues by further suggesting that AARP may be contemplating its role in the enterprise of personal retirement accounts for tens of millions of Social Security beneficiaries. We would be consistent since we previously were demagogues when we suggested that AARP’s interests might lie with supplemental Medicare coverage. But if it takes demagoguery to expand understanding, then so be it.

If AARP is to represent the seniors of our nation, it needs to be a strident voice in support of Medicare and Social Security. Sadly, it appears that it is merely using the seniors of our nation as a front to hide their nefarious support of moneyed interests, some of whom don’t want to pay Social Security taxes and others who do want to enrich themselves through the management of private retirement accounts. The seniors deserve much better.

The AARP board needs to be replaced with individuals who will tell CEO Bill Novelli where to go. And maybe he should take with him Erik Olsen, the AARP President-elect, who is former president and CEO of Delta Dental Plan of California.

November 11, 2004

Fail Globally, Act Locally

Fail Globally, Act Locally:Hotel Workers, Family Medicine, and the Future of Health Care
Kevin Grumbach, MD
November 11, 2004

Earlier this year, the San Francisco Chronicle quoted me as saying that my motto was, “Fail globally, act locally.” This was in the context of discussing my frustrating legacy as a physician advocate for universal health care, affirmative action, and primary health care. I thought about this motto this week as I pondered a dilemma that brought global issues in health policy home to a personal and local level.

Months ago, I accepted an invitation to be a keynote speaker at a national conference of family doctors and educators in family medicine scheduled for this weekend in San Francisco at the Hyatt Regency Hotel. I was honored to be invited to address the conference. Then, on September 29, 1400 hotel workers at four of the City’s major hotels went on strike—largely over a dispute about proposed increases in employee contributions for health benefits. Two days later, the hotel consortium The San Francisco Multi-Employers Group responded by locking out 2600 union workers at 10 additional San Francisco hotels, including the Hyatt Regency.

As the date of the conference approached, I experienced a sinking feeling. I watched the hotels dig in their heels and continue the lock out despite Mayor Newsom’s call for a cooling off period. I saw TV clips of the housekeepers and banquet waiters and prep cooks out on the picket lines, about to lose their health insurance. I thought about hundreds of conference registrants arriving in San Francisco, expecting to hear me deliver my plenary address on the theme of “Humanizing Care.” I wondered what I should do. Cross the picket line and swallow hard when giving my talk on making health care more humane? Cancel my talk on short notice and leave the conference organizers and my colleagues in the lurch?

I have much sympathy for the hotel workers. It’s not that my family traces its roots back to Mother Jones and had me singing Solidarity Forever in grade school (both my parents are physicians). And as a head of a medical school department, I am a “manager” and sometimes find myself contending with union grievances that seem more senseless than substantive. But the issues at stake in the hotel workers labor dispute are deeply meaningful—both to the workers involved and to the future of our nation’s health care system. At the core of the dispute is whether hotel workers in lower income jobs will be able to earn a living wage and afford health insurance. According to a September 2004 study by the UC Berkeley Labor Center, a full-time hotel room cleaner in San Francisco earns $2,611 per month. The “self-sufficiency” income required to pay for basic necessities for a single parent with a preschool age child living in San Francisco is $4,003. Currently, unionized hotel workers in San Francisco contribute $10 per month towards the purchase of family health insurance coverage. The new contract proposal by the Multi-Employers Group would require employees to contribute $32.53 monthly next year, rising to $273.42 in the contract’s fifth year.

The number of Americans with employment-based private health insurance has plummeted in recent years as employers drop coverage altogether or compel workers to assume a larger share of the cost of premiums—with the result that low wage employees are increasingly unable to afford to participate in their company’s health benefit plan. Between 2001 and 2003, 5 million fewer Americans were covered by employment based health plans, contributing to the surge in the number of the nation’s uninsured that has now reached 45 million. In my own practice as a family physician at the Family Health Center at San Francisco General Hospital, I care for many uninsured and marginally insured San Franciscans. I see first hand the hotel housekeeper with arthritis in her knees from a lifetime of making 40 beds a day, the banquet server with chronic dermatitis of his hands from carrying stacks of hot plates. The hotel concierges may be doing all right and not showing up at San Francisco General. But there are a lot of service workers behind the scenes in our city who are barely making ends meet, experiencing deteriorating health, and struggling to afford health care.

I also feel badly for the organizers of the conference. Conference planning requires booking venues years in advance and getting locked into hotel contracts that leave the organizers financially liable in the event of cancellations. The organizers of the family medicine conference have suffered a string of bad luck lately. The organization’s major annual conference in the spring of 2003 was scheduled to be held in Toronto, Canada. The only problem was that the SARS outbreak hit Toronto a few weeks before the conference date. The conference was cancelled days before the opening session. Who on the conference planning staff could have anticipated that the Hyatt would take the lead in an offensive lock out of its workers in the very city planned for the November 2004 conference? Conference registrants purchase their plane tickets in advance and carefully arrange their work and family lives to be in San Francisco for a 3 day meeting. How should they respond when they find out that hotel workers are picketing their conference hotel?

Conference organizers and participants are in a no-win situation when hotels use these types of tactics. For the courageous organization willing to take on a hotel and demand a rebate of all payments on the grounds that the hotel violated the terms of its conference contract by locking out workers, good luck! You will be spending a lot of time in court battling a multinational corporation in the “hospitality” industry represented by a top-dollar legal firm.

The people I don’t have any sympathy for are the hotel owners. As Mayor Newsom has pointed out, hotels like the Hyatt are no longer local businesses in touch with the local environment. These hotels are operated by huge conglomerates headquartered in distant cities, and have posted handsome profits in recent years. In their view, holding the line on employee pay and benefits is essential for sustaining this financial performance. I believe that this is a narrow view, breeding both resentful employees and disgruntled customers.

I decided not to attend the conference to deliver my keynote address. I had hoped to find some middle ground that would have permitted the conference organizers to use the meeting as an opportunity to educate attendees about the issues at stake in the labor dispute, allowing me to cross the picket line in good conscience and talk about the general topic of humanizing care while also addressing the immediate matter of the human rights of the hotel workers. But conference organizers get skittish about politics intruding on conference plenaries and being perceived as taking sides against the hotel. (The organization has another conference already booked for the Hyatt Regency in 2006.) I was gratified by the support I received from many colleagues about my decision, several of whom have decided to join the picket line at the Hyatt, reaffirming my faith that many health professionals desperately desire a more just system of health care in our nation.

I wish the hotel workers luck in their negotiations with the hotel industry, especially when it comes to preserving affordable health benefits. However, it is difficult to be optimistic about the future of health benefits for our nation’s workers. The US is facing the “perfect storm” of escalating health care costs and decreasing insurance coverage. I am skeptical that workers on the lower end of the wage scale will be able to avert continued deterioration of benefits under our current market-driven health care system. Maybe we should all start picketing together for the national health insurance system that is so long overdue in the United States.

Consumer-Directed Managed Care

Health Affairs
November/December 2004
Consumer-Directed Health Plans And The RAND Health Insurance Experiment
By Joseph P. Newhouse

What Was The RAND Experiment?

The RAND HIE (RAND Health Insurance Experiment) randomized families to health insurance plans that varied their cost sharing from none (“free care”) to a catastrophic plan that approximated a large family deductible with a stop-loss limit of $1,000 (in late-1970s dollars), which was scaled down for the low-income population. If one uses the rate of increase in per capita medical spending to convert late-1970s dollars into 2004 dollars, a $1,000 deductible then would be more than a $6,000 deductible is today.

The HIE participants in the large-deductible (95 percent coinsurance) plan used
25-30 percent fewer services than those in the free-care plan; on average,
they had just under two fewer face-to-face physician visits per person per
year and were 23 percent less likely to be hospitalized in a year. Substantial reductions in use were found among all income groups. But the heat in the hoary debate over the appropriate role for patient cost sharing was not the magnitude of any savings, but whether any reduction in use induced by increased cost sharing was among “necessary” or “unnecessary” services and therefore whether it adversely affected health. Those on the political left generally espoused the view that the services were necessary; those on the right, that they were unnecessary.

On this score, the results of the HIE had something for both sides. For most
people enrolled in the RAND experiment, who were typical of Americans covered by employment-based insurance, the variation in use across the plans appeared to have minimal to no effects on health status. By contrast, for those who were both poor and sick-people who might be found among those covered by Medicaid or lacking insurance-the reduction in use was harmful, on average. In particular, hypertension was less well controlled among that group, sufficiently so that the annual likelihood of death in that group rose approximately 10 percent. This adverse effect occurred in spite of the reduced cost sharing for low-income families, a feature generally not found in today’s plans.

http://content.healthaffairs.org/cgi/content/abstract/23/6/107

Comment: The RAND Experiment is of great importance because it is cited as
the rationale for creating consumer (patient) sensitivity to health care costs. This principle is the primary mechanism of controlling health care costs in the consumer-directed model of health care reform. We now have the advantage of having witnessed the debate, tempered by time, of the real impact of the RAND conclusions. Professor Newhouse provides us with an allegedly objective assessment of the RAND experiment from this historical perspective.

And what were the results? Most people, who are healthy and employed, remain
healthy even with cost sharing. But for those who are poor and sick, the reduction in use was harmful to their health, even resulting in death.

Although cost sharing does not have much of a negative impact on healthy people, it really does not decrease total health care spending much since most people are healthy and have much less need to access the health care delivery system. Keep in mind that 80% of individuals use only 20% of all health care services, and the reduction in utilization caused by cost sharing is a relatively small percentage of that 20% of total costs.

But what about the poor and sick? Cost sharing does reduce spending, but that reduction is in essential health care services. Significantly impaired health outcomes are absolutely inevitable.

Presenting the results of the RAND Experiment as an objective debate between
two sides that have an equal claim to the debate turf provides objectivity that is about as cold and calculated as the surveyor of battle scenes who report collateral damage in terms of statistical body counts. To suggest that the cost sharing debate has something for both sides ignores the fundamental issue that there is only one side to providing affordable health care access to those with significant medical needs.

Unfortunately, Professor Newhouse doesn’t stop there. Although he acknowledges the “counterrevolution against managed care,” he states:”How will the increased initial cost sharing mesh with managed care? I see them as complementary. One result of the RAND HIE was that the variation in cost sharing affected the likelihood of seeing a physician or other health professional about a medical problem, but it had only a small effect on the costliness of an episode once care was sought. By contrast, the tools of managed care aim primarily at the costliness of an episode.”

And…

”… higher initial cost sharing may make the instruments of traditional managed care more effective.”

Thus we enter the age of the grand experiment with Consumer-Directed Managed
Care. The body of health policy literature has already written the outcome:
suffering and death for those with greater health care needs.

Wouldn’t it be better to spend more of our $1.8 trillion on those who need health care?

November 10, 2004

Plaintiff Cry: When Retirees Sue an Ex-Employer

Sue an Ex-Employer
By Ellen E. Schultz
Staff Reporter of The Wall Street Journal
November 10, 2004; Page A12

When retirees of GenCorp Inc. were told the company was going to start charging them for health insurance, despite a labor contract they say promises coverage for life, John Van Dyke thought fighting back in court was the answer. “I was sure that once the judge saw the contract, it would be over,” the 76-year-old says. “How long could it take?”

So far, almost five years. What happened to the retirees shows the daunting challenges faced by the oldest Americans, union and salaried, if they go to court on their own to recover health benefits.

In January 2000, the former General Tire & Rubber began charging 2,063 hourly retirees health-care premiums. Mr. Van Dyke, a former millwright who once was active in the Rubber Workers union, quickly learned that it couldn’t help. In negotiating a contract in 1994, the union had agreed not to represent retirees in any future lawsuit.

On their own, the retirees faced their first challenge: finding a lawyer. Few lawyers take cases involving health benefits, because under the Employee Retirement Income Security Act, or Erisa, there are no punitive damages that contingency-fee attorneys can use to finance cases. All a plaintiff can win is restoration of the disputed benefit, and the judge may or may not let the plaintiff’s lawyer be reimbursed from that for the cost of preparing the case, thanks to a quirk in Erisa.

So Mr. Van Dyke passed the hat. He collected $12,000 from fellow retirees of a GenCorp plant in Jeanette, Pa. They chipped in $100 per couple, widows $50. While this would cover only a fraction of the cost of mounting a suit, he found lawyers who were willing to take the case. In August 2000, he met them at a diner in Pittsburgh, taking along a cardboard box full of union literature going back decades.

Told the suit needed named plaintiffs, he volunteered, along with fellow retirees Stanley Wotus and Ed Peksa. All three are World War II veterans who served in either Iwo Jima or Okinawa. (Veterans may qualify for some health care from Veteran’s hospitals, but there can be long waits for care and their spouses don’t qualify.)

In October 2000, they sued GenCorp in federal court in Akron, Ohio. The suit cited labor contracts promising lifetime coverage. But GenCorp, in court documents, responded that lifetime didn’t mean “at no cost.”

GenCorp also pointed to enrollment cards retirees filled out a decade ago. The cards asked the retirees either to pick a plan that had high deductibles and co-payments or continue in one that had no cost. They chose the no-cost option. But at the bottom of the form was fine print saying the signer acknowledged that “I am choosing the benefits selected on this form to replace any medical benefits available under any prior GenCorp retiree medical plan.” By signing the forms, GenCorp now argued, the retirees had released it from its obligation under the union contract.

In April 2001 came the first meeting with a judge. The retirees left early in the morning, first heading to a rendezvous with their lead lawyer. At the wheel was Mr. Van Dyke, who had the best eyesight. Still, at 5 a.m. in the dark on the Pennsylvania turnpike, he missed his turn, he recalls.

The retirees linked up with the lawyer, William Payne of Pittsburgh, who drove them the last 180 miles in his minivan, usually used to take his sons to hockey practice. Because of their various infirmities, they had to pull over several times. Mr. Van Dyke had part of his stomach removed following a bout of cancer in the 1990s. Mr. Wotus was taking several medications for blood pressure and heart problems. In the back seat, Mr. Van Dyke recalls, the diabetic Mr. Peksa had taken one insulin shot too many and was passing out. “I was worried about Ed. He’s got the sugar real bad,” Mr. Van Dyke says. They pulled over and gave Mr. Peksa some juice.

They finally made it to Akron in time for the 9 a.m. court session. There, the judge pressed the two parties to settle their differences. With nothing resolved, the retirees headed home.

GenCorp then said the plaintiffs should include retirees from other plant locations besides Jeanette, Pa. The judge agreed. So the retirees recruited more volunteers to serve as plaintiffs.

A year later, a larger group headed out, this time to a mediation meeting in Cleveland. Several retirees traveled from Kentucky and Ohio, booking senior-discount rooms at the Holiday Inn. Coming farthest was Kenneth Bottolfs, now 83. He made the three-flight trip from Waco, Texas, in eight hours. Mr. Bottolfs says the health-care premium for him and his wife is now $685 a month, more than erasing his GenCorp pension of $460. “A lot have dropped out because of the inability to pay” for the health coverage, he says. “My wife says they’re waiting for everyone to die.”

Fine Print

GenCorp argues it can change union retirees’ health benefits because of a line in enrollment forms they signed nearly a decade ago:
I have read the brochure which explains my retiree medical benefit options under the GenCorp plan, and I am electing to enroll in the coverages stated on this form.
I agree to pay any contributions, deductibles, and copayments required under the plan, and I authorize release of information on all claims submitted for payment.
I understand that I may change coverages only under limited circumstances. I acknowledge that I have choices available, and that I am choosing the benefits selected on this form to replace any medical benefits available under any prior GenCorp retiree medical plans.
The Cleveland meeting was to see whether the retirees and the company could resolve their dispute. It failed. The retirees began their long trips home. Eight months later, the retirees went to another mediation meeting, minus Mr. Wotus, who’d had a stroke. It failed too. The judge said the case should move to trial.
The retirees traveled to Cleveland on May 14, 2003, for depositions by GenCorp. The sessions took several hours each. The retirees whiled away their waits playing cards and trading war stories, says Mr. Van Dyke.

The following August, their lawyers filed to have the suit certified as a class action. Without this, even if the named plaintiffs won, no others would get their benefits restored.

Although GenCorp had insisted the plaintiff group be expanded to include people from around the country, and this was done, GenCorp opposed its certification as a class. It said the men didn’t qualify as representatives of the whole group of retirees. The reasons: Depositions showed some had forgotten what they were thinking when they signed enrollment forms. One didn’t remember what was in GenCorp’s slide presentation explaining the benefit options eight years earlier.
What’s more, the retirees had mixed their paper work when they pooled their brochures in a cardboard box while searching for a lawyer. That constituted “spoliation,” or destroying evidence, GenCorp said, adding it would “seek appropriate remedies at a later date.” Remedies in these situations can include charging retirees for a company’s legal fees.

Finally, GenCorp said the retirees should be denied class status because they were too dispersed, and because the named plaintiffs were too sick to adequately represent everybody.

Indeed, after GenCorp filed its brief, one plaintiff, Robert Berger, 69, died in October 2003. Plaintiff Frank Polumbo, who joined the company at 16, and as a youth took part in a 1934 strike that gave birth to the Rubber Workers union, died in November. He was 89. “He was a fighter, says his widow, Mary Elizabeth, 88, who volunteered to take his place.

In December 2003, Judge Dan Polster agreed with GenCorp and denied retirees’ request to be certified as a class. “I just couldn’t believe it,” Mr. Van Dyke says.
The retirees, fearing they’d all be dead by the time the case was resolved, and worried about a statute of limitations that the company said was running out, signed up an additional 294 plaintiffs and filed another suit in July 2004. In August, the judge dismissed that case. Now the 294 retirees, most in their 80s, must file individual suits by the end of January 2005, and each pay a $150 filing fee.

The original suit continues. In its latest quarterly filing, GenCorp said it didn’t expect a trial until after next summer. Its filings also show that over five years, GenCorp’s liabilities for retiree health care have declined 16%. The company declined to comment, citing ongoing litigation.

Mr. Van Dyke got out of the hospital last February after treatment for colon cancer. He had been caring for his wife of 58 years, June, who earlier this year had a stroke and a heart attack, but in September she died.

“A lot of people want to drop out” of the suits to restore company-paid health care, he says, “but I keep telling them to hang on.”

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The Corporate Transformation of Health Care

The Corporate Transformation of Health Care
Can the Public Interest Still Be Served?
By John P. Geyman, M.D.

From the Preface:
The economic boom of the 1990s, though it served many health care corporations and their investors well, has not been kind to U.S. health care. With more than 43 million uninsured Americans, and tens of millions underinsured, the health care system is collapsing around us. Inflation of health care costs continues unabated, rendering health care increasingly unaffordable to a large and growing part of the population, currently estimated at about 50%. Yet we are being told by corporate interests and many politicians in both parties that incremental reforms of our market-based system will be effective if we just give them more time.

This book provides an up-to-date analysis of the failing medical marketplace and suggests an approach to urgently needed structural reform.

Springer Publishing Company:
http://www.springerpub.com/books/public_health/pub_2466_6.html

Comment: John Geyman’s book provided my “escape literature” this weekend during my air travel between California and the national PNHP conference in
Washington, DC. How could a book that so aptly describes our very expensive but highly wasteful system that fails to provide quality outcomes ever be considered escape literature? Simply because it provides hope. There will be affordable, high quality, comprehensive health care for everyone once we adopt single payer reform. Books such as this make it clear that a universal social insurance program is an absolute inevitability.

Companies Sue Union Retirees To Cut Promised Health Benefits

Firms Claim Right to Change Coverage, Attempt to Pick Sympathetic Jurisdictions
The Process Server Pays a Call
By Ellen E. Schultz

Staff Reporter of THE WALL STREET JOURNAL
November 10, 2004; Page A1

When a deputy sheriff came to his door with a court summons, George Kneifel, a retiree in Union Mills, Ind., was mystified. His former employer was suing him. The employer, beverage-can maker Rexam Inc., had agreed in labor contracts to provide retirees with health-care coverage. But now the company was asking a federal judge to rule that it could reduce or eliminate the benefit.

Many companies have already cut back company-paid health-care coverage for retirees from their salaried staffs. But until recently, employers generally were barred from touching unionized retirees’ benefits because they are spelled out in labor contracts. Now, some are taking aggressive steps to pare those benefits as well, including going to court.

In the past two years, employers have sued union retirees across the country. In the suits, they ask judges to rule that no matter what labor contracts say, they have a right to change the benefits. Some companies also argue that contract references to “lifetime” coverage don’t mean the lifetime of the retirees, but the life of the labor contract. Since the contracts expired many years ago, the promises, they say, have expired too.

The companies taking such steps remain a minority. Most big employers continue to provide the retiree health coverage spelled out in labor contracts. But the number of employers using the courts to attempt to reduce benefits for union retirees is rising, and some have been successful. “There’s absolutely no doubt that there’s been an increasing number of cases over the past three years,” says Richard Brean, associate general counsel of the United Steelworkers of America.
They have little to lose by trying. Typically, as such legal cases drag on, the employers save money as some of the retirees, who have to pay growing portions of their health-care costs, forgo costly care, drop out of the plans or die. If companies lose in court, the worst that happens is they have to resume paying benefits. They don’t face punitive damages or penalties. And they may not have to resume benefits for those retirees who dropped out of the health plans. What’s more, their earnings get a pop. That’s because at the same time as they sue, employers typically announce reductions in the retirees’ benefits. Doing so entitles them to lessen the liabilities carried on their books. Lower liabilities translate to higher earnings.

The retirees, by contrast, often find themselves in a bind — unsure of their recourse and facing, as they age, the court system’s typical long waits for legal resolution. The U.S. Labor Department is of little help. Retired workers “aren’t our constituents anymore,” says a spokeswoman for the department.

Unions often do go to bat for retirees. The United Auto Workers and the Steelworkers have been the most active in filing suits to protect retirees whose benefits a company has unilaterally changed. But unions aren’t allowed to strike or file unfair-labor-practice complaints on behalf of retirees.

Employers that want to cut union retirees’ health coverage or make retirees pay a larger portion could just impose changes and wait to be sued. But by suing first, they stand a chance of choosing the jurisdiction. This is important, because federal circuits’ appellate courts tend to take differing positions in these disputes. Indeed, the unsettled nature of the law on these issues — with employers’ arguments sometimes succeeding and sometimes not — may be a factor prompting some companies to have a go at gaining the legal right to change benefits.

One afternoon last December, Basil Chapman was sitting on his porch in Barboursville, W.Va., with his dog, Bo, when a union representative phoned the retiree to say an executive of his former employer wanted to speak to him. Mr. Chapman called the executive, at ACF Industries Inc., a railroad-car maker where Mr. Chapman worked for 38 years. He was told ACF was going to change health coverage, making retirees pay for a portion that previously was free.
“We have a contract. You can’t do that,” Mr. Chapman said, according to court papers later filed by ACF. “We will file in federal court against you b——-ds.” Asked about this, Mr. Chapman, who is 60, says he didn’t swear on the phone.

The next Monday, ACF, which financier Carl Icahn controls through an investment vehicle, sued Mr. Chapman in federal district court in St. Louis. The company asked the court to rule that it had the right to change or terminate health coverage for 678 retirees and their dependents. ACF said it was suing to protect itself, noting that “defendant Chapman has already informed ACF that he plans to file a lawsuit concerning the amendments of the plan.”

“I can’t understand why they’re picking on me,” Mr. Chapman says. “I’m just a retired guy who was sitting on my porch.”

CO-PAY BLUES
This week, the Online Journal looks at the financial burdens facing health-care consumers who have insurance and offers advice on handling medical expenses.
Do you have questions or ideas about selecting health-care coverage and managing your family’s costs? We invite you to participate in a discussion2 with health-insurance and benefits experts.

Monday: The lines between HMOs and PPOs are blurring. Here’s how to choose3 the right plan option for you.

Tuesday: Dr. Benjamin Brewer, in his Doctor’s Office column, talks about how insurance coverage affects the patients4 that doctors agree to service.

Thursday: Fiscally Fit columnist Terri Cullen focuses on the quandary patients face when health-care providers charge more than what insurers will pay.

Employers that sue retirees name one person or a handful. They may choose people at random, retirees who have complained, or people who were active in the union that negotiated the contract at issue. Mr. Chapman, who repaired equipment and stenciled names on railroad cars at ACF, also headed a Steelworkers bargaining committee. The named defendants represent the “class” of retirees.

Key Contract Element
Mr. Chapman says health coverage for retirees was a key element of labor contracts he helped negotiate in 1995. Up to then, although the company paid 100% of hospitalization and surgical coverage, retirees paid for major medical. But their premiums for that coverage had risen so high that many had dropped it.
To make health coverage affordable for future retirees, the union accepted lower starting pay for new workers in exchange for lower-cost major medical coverage for retirees. According to the contract, any employee retiring during the term of the agreement “will contribute a flat $100 per month for life towards the cost of such coverage. The Company will pay any additional required costs.”

The company doesn’t dispute that the contract says that, but it says that “$100 per month for life” referred only to the major medical coverage, not explicitly to the hospital/surgical portion.

In addition, it believes the agreements to provide health coverage to retirees expired with the contracts, said Marc Weitzen, general counsel for ACF at Icahn & Co. in New York, in an interview.

The retirees, represented by the union, countersued to dismiss the complaint. They contended ACF had gone through “the charade of telephoning retiree Mr. Chapman about the cuts, just so it could provoke a predictable negative reaction and then use the reaction to immediately sue.”

The retirees said ACF had sued in St. Louis, which is part of the 8th federal circuit, because it “apparently believes that the 8th Circuit is more favorable to employers in retiree medical benefits cases, and apparently feels that its chances are improved if it makes the retirees litigate hundreds of miles from their homes.”

CREATIVE STRATEGIES

Companies that cut retiree health benefits promised in writing may use one or more arguments or tactics:
” Escape Clause: Insert sentence in benefit plan saying company “reserves the right” to change benefits.
 
” ‘Life’ Line: Argue that “lifetime coverage” refers to life of the contract, not lives of retirees.
 
” Fine Print: Say that retirees signing health-plan enrollment forms waived prior agreements.
 
” Trip to Court: Sue retirees, ask court to declare company has right to cut benefits.
 
Source: WSJ research

Most of ACF’s retirees live in West Virginia, in the 4th Circuit, where a court favored union retirees in an earlier decision. The retirees asked the judge to dismiss the case or transfer it to the southern district of West Virginia.

Mr. Weitzen at Icahn & Co. said ACF sued in Missouri because it administers the benefits plans from there. He added, “As with many other U.S. businesses, ACF believes it has the right to pass along certain of its health-insurance costs to retirees.”

It is legal and common for litigants to try to pick a favorable jurisdiction. If two parties sue each other, the courts generally hear the case that’s filed first. But a court can dismiss or transfer a case if it believes a company is “forum shopping” or suing retirees as a pre-emptive strike to deprive them of their rights, as “natural plaintiffs,” to sue in the court they would choose.

That happened in this case. In August, the court in St. Louis — saying it appeared ACF’s move “resulted in a proverbial race to the courthouse in order to deprive defendants of their choice of forum” — moved the suit to federal court in Huntington, W.Va. The case is ongoing.

But a different court came to the opposite conclusion regarding Rexam, illustrating why employers make these legal thrusts at retirees.

In early 2002, Rexam raised retirees’ share of the cost of prescription drugs. “For people getting a pension of $300 to $400 a month, it ate their whole pension,” says Mr. Kneifel, the retiree in Union Mills, Ind., who is 65.

For more than a year, retirees complained to the company that it had no right to change negotiated agreements, which stated that “Company-paid major medical coverage will be provided for all retirees,” and specified what the retirees’ costs would be.

‘Reserves the Right’
Rexam responded that a booklet describing the coverage contained a clause that said the company “reserves the right to amend, modify or discontinue the plan in the future in conformity with applicable legislation.”

The retirees said the clause meant that if government legislation or regulations changed, then the plan might have to be modified accordingly. It didn’t give the company a right to unilaterally change the agreement, retirees said, pointing to another clause specifically stating that the right to modify the benefits “was subject to any applicable collective bargaining agreement.”

In May 2003, Rexam sued the retirees, asking a federal court to declare that it had the right to change their benefits.

It filed in Minneapolis. The appearance of a deputy sheriff bearing a summons to court 475 miles away was a shock to Mr. Kneifel. “I’m glad I was home when they came, because my wife had a stroke about six years ago,” he says. “Suing retirees is a cowardly way to go about the whole thing.”

The retirees, represented by the Steelworkers, countersued in Toledo, Ohio, asking that the case be dismissed or transferred there. They said Minnesota was home to only 100 of the 3,600 retirees and that Rexam had made a pre-emptive legal strike to choose the jurisdiction. The business, which was called American National Can Co. before its 2000 purchase by Rexam Inc., is based in Chicago and has offices in Charlotte, N.C. It is a subsidiary of Britain’s Rexam PLC. The judge in Minneapolis rejected the retirees’ arguments. Because they had not been planning to sue Rexam, they couldn’t claim Rexam was suing in a pre-emptive strike, said Judge Ann Montgomery. She let the case stay in Minneapolis because Rexam employs 115 people in St. Paul and has retirees in Minnesota.

Judge Montgomery also said she was allowing the suit to move forward “in the interests of justice.” She cited a liability for the benefits on Rexam’s balance sheet and said the company was harmed “because it cannot lower the liability unless it reduces the retirees’ benefits.” The case is pending.

A Rexam spokesman said with health-care costs rising, the company “must do what we can to address these costs” to remain competitive, but will continue to provide retirees with fair coverage.

Gradual Erosion

The erosion of legal protection for retiree health benefits has been gradual. When medical costs began to rise steeply in the 1980s, employers first started to cut benefits for salaried retirees. If sued, employers pointed to clauses they had added to the health plans’ technical documents. The clauses said the employer reserved the right to change the benefits.

Retirees complained that the clauses were buried in long technical documents they often didn’t know existed. (Companies must provide employees a summary of these documents when they first become health-plan participants; the summaries may or may not include the clauses at issue.) The retirees also pointed to employer literature referring to lifetime coverage. Nonetheless, courts began accepting company arguments.

A key case involved cuts by General Motors Corp. in coverage it had offered to 50,000 salaried employees over the years to induce them to retire early. A 6th Circuit appellate court ruled in 1998 that what mattered weren’t brochures that advised prospective retirees that health coverage would be provided “at GM’s expense for your lifetime,” but a clause in which GM reserved the right to alter benefits. Although dissenting judges assailed this reasoning, and the federal circuits remain divided about it, salaried retirees have steadily lost in benefits cases ever since.

Union retirees were more secure because their benefits were part of negotiated contracts. But after the GM ruling, more employers began to argue that that decision’s logic applied to union retirees, as well, and some courts agreed.

Meanwhile, over the years some employers also have argued that promises of lifetime coverage expired when the contracts expired, or were canceled out by clauses noting how long the contracts would run. Initially, courts rejected those arguments, saying general “duration clauses” in contracts refer simply to the period of the contract, and pertain to salary and benefits for active employees, not to benefits for retirees.

But some courts in the past decade have accepted these employer arguments. The federal circuits are split. Retirees who go to court on their own to contest cuts in their benefits face a hard road. Employers generally use a combination of arguments when they unilaterally change union retirees’ health coverage and file suit against the retirees.

Serving Papers
Asarco Inc. told retirees in mid-2003 that it was raising their health-care premiums. As it did so, the copper company sent summonses to some retirees in Arizona, where many live, telling them they were defendants in a suit it was filing in Phoenix.

The suit pointed to a clause in health-plan documents saying, “The Company reserves the right to amend or terminate the Plans at any time for any reason.…even after you retire.”

In addition, Asarco pointed to general “duration clauses” in the contracts, which said the agreements expired when the labor contracts did. The agreements that expired, the company said, included the one to provide retirees with health coverage until they qualify for Medicare.

Retired Asarco miner Chuck Yarter learned he was being sued when he got a call from a process server trying to find his remote home in the Sonora Desert near Marana, Ariz. Mr. Yarter, 61, says he told the man how to find his modest 625-square-foot house, which sits at the end of a dirt road, with a distant view of the open-pit Silver Bell copper mine where Mr. Yarter was a mechanic on heavy equipment.

He smiles recalling the visit: His black dog, Lady, wouldn’t let the visitor out of his car. The process server handed the papers through the car window before trundling away through the saguaro and mesquite. “I’ve never been served papers in my life,” Mr. Yarter says.

In its July 8, 2003, letter to him and other retirees, Asarco, a unit of Grupo Mexico SA, said: “As you know, the past several years have been very difficult for the copper industry. The continuing low copper prices and escalating medical costs force us to make these changes.”

Mr. Yarter, who monitors copper prices on the Internet, says Asarco is just making excuses. Copper prices have nearly doubled since the July 2003 letter, to about $1.36 a pound from 76 cents.

Asarco, in a statement, said it acted in response to “the constantly escalating” cost of providing medical and drug coverage, saying it must control costs because it can’t control what it gets for its copper. It said it continues to make coverage available “at a reasonable cost,” declining further comment because the case is in litigation.

Three unions filed a counterclaim on retirees’ behalf against Asarco: the Steelworkers, the International Brotherhood of Electrical Workers and the International Chemical Workers. The retirees’ suit says that the duration clauses weren’t meant to limit the retirement benefits of people who had already retired, “as such retirement benefits were meant to last during retirement independent of the expiration of agreements applicable to active employees.”

It added that the “alleged ‘severe financial distress’ has not prevented the Company from paying its top management quite handsomely.” And it said that ” ‘unforeseen circumstances’ do not justify a breach of contractual obligations … to persons living on fixed income who can ill-afford to pay the costs the company has shifted upon them.”

Since Asarco imposed the changes, Mr. Yarter’s share of premiums, deductibles and co-payments has grown to consume half of his $1,005 monthly pension. He says he is staying in the plan anyway, because his wife, Frances, has diabetes.
But Larry Bracamonte, 64, with a pension of $448 a month, is among Asarco retirees who have dropped the plan as a result of the increase. He works at a furniture store, and twice a month, he drives a van full of Arizona retirees five hours to Algodones, Mexico, to buy prescription drugs more cheaply than in the U.S. He says a neighbor can’t afford even the lower-cost Mexican drugs on her Asarco widow’s pension of $54 a month, so she gets drugs from a state program for low-income people.

Mr. Yarter says he’s in better shape than many Asarco retirees. “I did all the retirement planning you’re supposed to do,” he says. “I decided I could afford to retire.” After retiring, he studied computer programming and obtained an associate’s degree in systems administration.

Now he’s looking for work, so far without success. “If the company kept its promise, I’d be all right,” he says. “Nobody ever thought the company would try to renege on a contract like that.”

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November 08, 2004

Our 'Kindness Deficit' of Care

Newsweek, November 8 
Jane Bryant Quinn
 
Our ‘Kindness Deficit’ of Care

After the third presidential debate, the plight of those without health insurance vanished from political sight. No surprise there. Lack of medical care represents a moral lapse that voters love to tut-tut about but aren’t moved to fix. Fixing it might cost money, at which point the moralists usually change the subject to the weather. Besides, the uninsured tend to be powerless people whom America’s comfortable middle can ignore.
 
A cynical judgment? Sure, but true. If we cared, public policy would have changed long ago. When the elderly scream about the cost of prescription drugs, ears prick up. But 80 percent of the 45 million uninsured are what Princeton health-care analyst Uwe Reinhardt calls “low-income, hardworking stiffs “waitresses, taxi drivers, clerks, nursing-home aides, gas-station attendants. They swing no weight among policymakers; no lobby represents them; their pockets aren’t deep enough to buy congressional attention. Working stiffs have to depend on the kindness of strangers and we’re running a kindness deficit.
What’s more, failing to cover 45 million people is, indisputably, a bargain.

The uninsured received $48 billion in free or government-paid care last year (less than they needed, but so what?). Insuring them could cost about $96 billion more. Ooooh, that would raise taxes, so we look away.But does it have to raise taxes? Imagine, for a blessed moment, that we ditched our costly, inefficient, bureaucratic, paper-pushing, interfering private health insurers in favor of a single government-run system for example, Medicare for everyone. The savings in administrative costs alone could reach $325 billion, says Dr. David Himmelstein of the Harvard Medical School. Taxpayers already cover 61 percent of American health-care spending (counting both subsidies and direct payments). If that money didn’t have to be funneled through private insurers, who take 20 percent or more off the top, we could have universal care at no increase in cost.

Any rant against our carelessness toward the uninsured requires statistics, so here they are: among all working people, 61 percent receive employer coverage, down from 65 percent in 2001 (Kaiser Family Foundation). One out of three people under 65that’s 85.2 millionwent uninsured at some point during 2002-03 (Families USA). The proportion of doctors giving charity care dropped to 71.5 percent in 2001, from 76.3 percent in 1997 (Center for Studying Health System Change). Among people 51 to 61, the uninsured are 63 percent more likely to suffer declining health, over a four-year period, than the insured (Center on an Aging Society). All of us “comfortables” stay insured only because we keep our jobs or can afford to pay private-insurance premiums, whose cost has been soaring at three times the rate of earnings over the past four years.

Nevertheless, Big Medicine holds enough power to beat down true reform. You
can still be spooked by phrases like “government-run health care,” even though that defines Medicare, which you want more of. You’re also hearing a fierce assault on Canada’s universal coverageclaims that patients get poor care, wait months for treatment and flee to the United States for surgery. In truth, only a fraction of 1 percent of Canadians seek care in the United States, says health expert Steven Lewis of Access Consulting in Saskatoon, Saskatchewan. Canada does have waiting lines of eight to 12 weeks for surgery not considered urgent, owing to ceilings on what the government will spend. Maybe more patients would come south if they could afford it. But for most, the wait seems a reasonable trade-off for coverage that’s broad, universal and secure. Anyway, the United States doesn’t have to go that route. We spend nearly twice what Canada does per person. If that same money were applied to a universal program here, no one would wait. Canada outscores the United States in such basic health measures as longevity and infant mortality (not to mention cheap drugs and flu shots). “If the purpose of a health-care system is to improve health,” Lewis says, “Canada wins hands down.”

All health systems have pluses and minuses; all ration health care in some way. We ration it, harshly, by income and price. People with money and access command topnotch care. Those without scramble for what they can get. Big businesses negotiate good group-health insurance. Small businesses are pushed against the wall. The healthy find private policies, the sick get kicked out. That’s the American Way.The next Congress may give a nod to the uninsured, says Karen Davis, head of the Commonwealth Fund, which studies health policy. Maybe tax credits for people who lose their jobs, to help them buy interim, COBRA coverage, or eliminating the two-year waiting period that keeps the disabled from Medicare.

But will we make a fundamental fix? Nah. Too many rich, corporate players have a stake in the status quo. Princeton’s Reinhardt distills our chosen policy this way: the suffering of a few million Americans, while regrettable, is a price well worth paying for fine coverage for the rest of us. What’s really regrettable is that that sounds, to most Americans, OK.

November 05, 2004

A crisis too loud to ignore

A crisis too loud to ignore
Nov 5, 2004
By: Robert Lowes
Medical Economics

I began writing this in a hotel bathroom in San Francisco. Only there could I escape the racket of a picket line 20 floors below and hear myself think: Maybe doctors shouldn’t view national health insurance as a dirty idea.

The pickets were bellhops, waiters, room cleaners, and the like. Their union had struck four hotels; 10 other hotels had locked out their union employees in response.

I had a window on this war from my room at the Renaissance Parc 55. Its workers weren’t striking, but I could see picketers across the street at the Hilton. Some carried signs reading “Healthcare is a Right” while others drummed buckets, blew whistles, and chanted from 7 a.m. to 10 p.m., the limits set for noise-making. A renegade drummer woke me up at 2 a.m. Earplugs courtesy of the hotel were useless.

The din was unnerving but understandable. A proposed contract would increase a worker’s health in-surance premium from $10 a month, an unbelievably low amount, to $273.42 a month in five years, an unbelievably high amount. That’s more than my premium, and I make more than they do.

I asked Violeta Sarmiento, a 58-year-old housekeeping supervisor, whether she could afford $273.42 a month in premiums.

“Oh, my God, no,” said Sarmiento. “It’s too much; we can hardly pay our mortgage now.”

But shouldn’t employees assume a bigger share of the healthcare tab?

“No, no, no,” she said. “We’re not going to give Hilton anything from our pocket. They earn billions.”

Sarmiento has a point. Like other businesses, Hilton faces skyrocketing healthcare costs, but it earned $112 million in the first half of 2004.

Nationwide, millions of laid-off workers have lost insurance coverage. Millions more who’ve kept their jobs find it costlier. You, of course, encounter this crisis every day. If you’re like the doctors I know, you respond quietly but heroically by treating that hard-pressed, uninsured patient and tearing up the bill.

But this generosity applies the proverbial Band-Aid to a systemic problem. So what’s the systemic solution? “We don’t have national health insurance,” said Tim Miller, a waiter turned picket captain. “Shame on America.”

Maybe national health insurance strikes you as socialized medicine. But our society must replace the current system with something that’s fairer and more compassionate. I was heartened by the report of a surgeon who grabbed a sign and joined the hotel strikers. If anybody has the moral authority to provide leadership on this issue, it’s the healing profession.

The presidential election is over, but the crisis remains. Whatever we do, we can’t succumb to the temptation to stick in earplugs. Otherwise, the drumming will only get louder.

November 04, 2004

The Defeat of California's Employer Mandate

Other changes in health care may be sought
By Barbara Feder Ostrov
The Mercury News - Nov. 4, 2004

These comments are in response to the relatively narrow defeat of Proposition 72, California’s play or pay employer mandate.

Any “son of Proposition 72” proposals would need to incorporate cost controls and ease the financial burden on smaller businesses, said Rick Brown, who heads the University of California-Los Angeles Center for Health Policy Research.

“Everybody knows that the one option we don’t have is the status quo,” said Anthony Wright, executive director of the advocacy group Health Access. “The health care system is unraveling. People see it every time an employer scales back and drops coverage, every time an emergency room closes.”

http://www.mercurynews.com/mld/mercurynews/living/health/10096491.htm

Comment: The majority of voters are healthy and they have insurance coverage. They are concerned about health care costs, but they are even more concerned about disruption of their current perceived health security. Our message to them will have to be crafted to show them that we can provide significantly greater financial and health security. Let’s work on it.

November 03, 2004

FDA Memo Indicates Vioxx Might Have Contributed to About 27K Heart Attacks, Death

Wednesday, November 03, 2004
Coverage & Access
FDA Memo Indicates Vioxx Might Have Contributed to About 27K Heart Attacks, Deaths

Arthritis medication Vioxx, which maker Merck voluntarily withdrew from the market in September, might have contributed to an estimated 27,785 heart attacks and sudden cardiac deaths between 1999 and 2003, according to an FDA memo published online Tuesday, the Bloomberg/Baltimore Sun reports. David Graham, associate director for science in FDA’s office of drug safety and author of the memo, made the estimate based on 92.8 million U.S. prescriptions for Vioxx between 1999 and 2003. According to the memo, 27,785 more patients taking Vioxx may have had heart attacks, some causing death, than those taking Celebrex (Bloomberg/Baltimore Sun, 11/3).

Part of Earlier Study
The memo is part of a study Graham conducted with Kaiser Permanente (Bloomberg/New York Times, 11/3). For that research, Graham and colleagues examined records for 1.39 million members of Kaiser Permanente, including 26,748 who took Vioxx and 40,405 who were on Pfizer’s COX-2 inhibitor Celebrex. The study found that high doses of Vioxx, or rofecoxib, tripled risks of heart attacks and sudden cardiac death. Graham planned to present the findings at an epidemiology conference Aug. 25, but his supervisors said the results were “too preliminary” and recommended that the study be submitted first to a medical journal so it could undergo peer review or be presented at the conference with an alternative FDA opinion. When the study was presented Aug. 25, the abstract said, “[T]his and other studies cast serious doubt on the safety of rofecoxib … and its use by physicians and patients” at doses exceeding 25 milligrams. “When Graham submitted a revised, final version to FDA on Sept. 30, FDA’s announcement of the study’s release did not mention specific data on cardiovascular risks (Kaiser Daily Health Policy Report, 10/8).

Internal Documents
Prior to Merck’s withdrawal of Vioxx, about 20 million U.S. residents had taken the medication. The Wall Street Journal on Monday reported that internal e-mails, marketing documents and interviews with outside scientists who questioned the safety of Vioxx indicated that Merck was aware of safety concerns related to the medication and sought to hide them to protect sales. The internal documents are among those presented as evidence in lawsuits filed against Merck since 2001 on behalf of former Vioxx users who allegedly experienced heart attacks or strokes as a result of the medication (Kaiser Daily Health Policy Report, 11/1). Merck’s shares declined 5.2%, or $1.48, to $26.80 on Tuesday, following a 9.7% loss Monday when the internal documents were revealed (Talley, Wall Street Journal, 11/3). Merck’s shares have declined 42% this year.

Reaction
Merck spokesperson Chris Loder said, “In general, there is no reliable way to measure the actual use of Vioxx in the population, and therefore no reliable way to estimate the actual events. Because heart attacks and strokes occur in the general population, one cannot say that if someone had an event while taking Vioxx, that Vioxx caused it.” Analyst Ira Loss of Washington Analysis said, “We are in a situation where there seems to be no end to negative reaction for Merck, even if the news has been previously reported” (Bloomberg/Baltimore Sun, 11/3). The FDA memo is available online. Note: You must have Adobe Acrobat Reader to view the report.

Vote!

MSN Money
(Accessed 11/2/04)
Bush, Kerry and the great health-care divide
By Philipp Harper

They receive about half as much medical care as the rest of us, and as a result get sicker faster and die younger.

They’re the 44 million Americans who this year will live their lives without the benefit of a health insurance safety net. How they’re regarded by their fellow citizens could be one of the key turning points of the upcoming presidential election.

The question is simple: Do they represent a vexing cost or an unprecedented investment opportunity?

The candidates have voiced their opinions and they couldn’t be in sharper contrast.

At its most basic, the debate over health care is about how large a role the federal government should have in our economic lives. As such, it crystallizes like few other issues the philosophical divergence between Republicans and Democrats.

The fact that a new revenue source would have to be found to pay for the out years of the Kerry health plan has Republicans screaming “tax and spend.” What that label ignores, however, is that federal spending to promote a healthy population may constitute an investment rather than an expense.

Some voters will view that spending as an investment leading to a fine return, others as a confiscatory tax. Which viewpoint holds sway could well determine who occupies the White House for the next four years.

http://moneycentral.msn.com/content/Insurance/Insureyourhealth/P95373.asp
Comment: If you have not done so already, go out and vote. Now!

November 02, 2004

Susan Dentzer's Innovative Proposal for Reform

It’s the Taj Mahal of Health Insurance Schemes
By Susan Dentzer (health correspondent for “The NewsHour With Jim Lehrer” on PBS)
The Washington Post - October 31, 2004

Following are excerpts from Susan Dentzer’s response to a Washington Post news story of an uninsured carpenter from Durham, N.C. who outsourced his own heart surgery to India, at a cost of $10,000, including transportation. He could not afford the $200,000 his surgery would have cost in this country.

Good grief, why didn’t someone think of this earlier! Forty-five million americans lack health insurance, and covering every one of them would be costly. Why not outsource them all to India?

Opponents will immediately say this idea is impractical. I say, don’t be health coverage girlie men! First, not all the uninsured would have to travel to India to get health care. For example, when an uninsured person first got the sniffles, he or she could pick up the phone and talk with someone at a call center in, say, Bangalore. An Indian nurse making $10 a day would listen (sympathetically, of course) and offer advice.

For those uninsured in need of hands-on medical care, here’s an idea: What if some of those failing U.S. airlines converted to running medical air shuttle services between, say, New York and New Delhi, or Boston and Bombay? Uncle Sam could hire them as private contractors, then pay them to ferry the uninsured back and forth.

The more I think about this idea, the better I like it. Just imagine all the problems it would solve: No more overcrowded emergency rooms choked with uninsured patients. No more worries about a nursing shortage; by transferring our patients to India, we’d outsource nursing care there, too. Hospitals and doctors here would be freed up to do what makes most sense for them economically: treat well-insured patients at steep prices — even to the point of giving them care that they probably don’t need! Perform the most lucrative elective surgeries on relatively healthy patients, rather than giving high-cost care to the sickest loss leaders!

We all know the uninsured are a terrible problem, an embarrassment, really, for such a rich country as ours. Every other major industrialized nation has figured out how to provide health coverage to most, if not all, of its citizens. At last, here’s a twist on globalization that could really work for everybody. So let’s get started. Who says Americans can’t take care of their own?

http://www.washingtonpost.com/ac2/wp-dyn/A11196-2004Oct30?language=printer

Comment: Susan Dentzer’s proposal certainly should embarrass us all. The $1.8 trillion that we are already spending on health care is more than enough to provide high quality, comprehensive health care for absolutely everyone. Her facetious proposal stands in stark contrast to well understood and effective policy solutions that would provide us with an affordable health care utopia. When we already have the resources, we should be ashamed that we continue to allow them to be frittered away when there is so much unmet need.

Appropriate are comments from today’s USA Today editorial on the president’s challenge to unite the nation:

“Almost every expert agrees that the (health care) system is not sustainable, and 70% of voters polled Tuesday said they were ‘very concerned’ about the availability and cost of health care.”

“The first step toward a bipartisan approach is to agree on universal coverage as a goal and be honest about its cost.”

“Only with a common starting point is there any hope of fighting off the lies spread by the interests that profit from the weaknesses of the current system.”

http://www.usatoday.com/news/opinion/editorials/2004-11-03-our-view_x.htm

(Being honest about costs includes being completely honest about the advantages and disadvantages of government versus market mechanisms of controlling costs.)

November 01, 2004

The View From Vermont

by MORTON MINTZ

[from the November 15, 2004 issue of The Nation]

Dr. Deborah Richter has advocated state-sponsored health insurance for every Vermonter, at nearly fifty Rotary Clubs plus chambers of commerce and boardrooms. The reservations she heard from the business community are (1) they don’t trust the government with healthcare, and (2) they fear that initially acceptable tax rates would soar as people came to view universal health coverage as a “blank check.” “I agree with the business community to some extent,” Richter told me.

Under universal healthcare, decisions would have to be made about “egalitarian rationing,” so as to meet everyone’s basic needs while denying some things to anyone.

To pay the bills, public funds now financing Medicare, Medicaid and other government programs would, with a federal waiver, be funneled into a unified system. Payroll taxes—5.8 percent on employers, 2.9 percent on employees—would replace premiums and deductibles. There would be a $10 co-payment for most services. The annual cost to employers would be about $1,450 per worker, far less than the cost of insurance premiums. “Savings could go to prevention and public-health improvement, further reducing long-term costs,” Richter said. “Losing or changing jobs would not mean losing or changing health insurance. Most families and employers now paying for insurance would have decreased costs. Family impoverishment and bankruptcy due to illness would be eliminated. The cost-shifting that plagues our hospitals would be eliminated.”

Richter senses “an increasingly positive response” to this plan because business people, especially manufacturers, are “getting killed” by the rising costs of healthcare. And they are disturbed—”feel like they’re reneging”—when they must cut back benefits, she said. One employer of 100 Vermonters, hit by a 58 percent rise in a single year and expecting a 15 percent increase on top of that the next, told Richter he was thinking of moving his operation to Canada.

Richter believes the current system focuses excessively on payment for care of the sick—”pay as you go,” she calls it. The “nutshell problem” with this is that it demands “a massive bureaucracy to limit individual utilization and to administer payments,” she says. “The number of healthcare administrators needed to limit individual utilization” increased 2,500 percent between 1970 and 2000, while the number of doctors increased by only 150 percent, she pointed out.

“Yet pay-as-you-go does not guarantee healthcare to each of us should we get sick or be injured,” Richter continued. “People who need disease management to avert, delay or moderate serious medical disorders don’t get it. Diabetics are an example. How can they get disease-management without health insurance? And how can they get that insurance when for insurers—businesses whose first obligation is to the shareholders—the game is to insure healthy people? “We’re headed for a train wreck,” Richter warned. “We must replace pay-as-you-go, with its emphasis on individuals, with the ‘investment model,’ in which the whole society invests in a public good that we all may need but cannot provide for.”

Single-Payer: Good for Business

by MORTON MINTZ
[from the November 15, 2004 issue of The Nation]

Business leaders complain endlessly that the current system of private healthcare insurance based on employment provides fewer and fewer people with less and less quality care at higher and higher cost. Yet Corporate America turns its back on a publicly financed system, which, by all indicators, the taxpayers would willingly support.

Publicly financed but privately run healthcare for all—including free choice of physicians—would cost employers far less in taxes than their costs for insurance. Universal coverage could also work magic in less obvious ways. For example, employers would no longer have to pay for medical care under workers’ compensation, which in 2002 cost them more than $38 billion. Auto-insurance rates would fall for them—and everyone—if the carriers were no longer liable for medical and hospital bills. You’d think that in its own selfish interest, Corporate America would be fighting to replace the existing system with universal health coverage. Yet it doesn’t lift a finger.

Meanwhile, under the Bush Administration healthcare coverage steadily shrinks. In 2000, according to the Census Bureau, 14 percent of Americans didn’t have it; in 2003, 15.6 percent—45 million—did not. Actually, 85 million Americans under age 65 were uninsured over varying periods during 2003-04, up from 81.8 million in 2002-03, according to Families USA, the consumer health organization. As more and more Americans become uninsured, spending on healthcare soars. By 2001 it accounted for 13.9 percent of US gross domestic product. (It constituted a much smaller share of GDP in countries with universal healthcare, such as Sweden, 8.7 percent; France, 9.5 percent; and Canada, 9.7 percent.) Average family premiums in 2005 are projected to be $12,485, up $1,768 from 2004. The federal Centers for Medicare & Medicaid Services expects healthcare outlays to rise from $1.8 trillion in 2004 to $2.7 trillion in 2010, nearly a trillion-dollar increase in six years. The forecast reflects annual increases of 14 percent to 18 percent. David Walker, head of the Government Accountability Office (GAO), the auditing arm of Congress, calls them “unsustainable.”

A simple fact largely explains why spending bloats while the ranks of the insured thin: Health insurance is increasingly unaffordable. After rising 38 percent between 2000 and the last quarter of 2003, the costs of providing healthcare to employees rose 11.2 percent between January and May of 2004, according to the Kaiser Family Foundation’s annual survey of 3,000 companies. “Close to 75 percent of 205 senior-level executives surveyed [in May] by the Detroit Regional Chamber rank employee health insurance as ‘unaffordable’ and 25 percent consider it ‘very unaffordable,’” the Detroit News reported. The Kaiser Family Foundation says that from 2001 to 2004 the proportion of workers receiving health coverage on the job dropped from 65 percent to 61 percent, a loss of 5 million jobs with health benefits.

“Double-digit increases in healthcare costs are a drag on economic growth,” says Henry Simmons, president of the National Coalition on Health Care, an alliance of groups working for healthcare reform. They “slow the rate of job growth,” “suppress wage increases for current workers,” “undercut the viability of pension funds,” “put American firms at a steep disadvantage in world markets” and produce “severe long-term budgetary problems” for the federal and state governments.

Two unrelated but mutually reinforcing reports coming out on a single day, August 19, validate the economic-drag theory. First was a study that found a “relationship between job growth and health-care costs” in eighteen industries between 2000 and 2003. It was done for the Kerry campaign by Sarah Reber, assistant professor of policy studies at the University of California, Los Angeles, and Laura Tyson, dean of the London Business School and former head of President Clinton’s Council of Economic Advisers and National Economic Council. The evidence, the authors write, “suggests that employers have reduced hiring in response to rising health insurance premiums,” and that rising premiums have led to a deterioration in the quality of jobs. In industries where health-insurance benefits accounted for a comparatively large share of total employee compensation, job growth was slower than in industries where they accounted for a smaller one.

Thus, in the accommodation and food services industry, “benefits constituted about 12 percent of total compensation for workers…and jobs grew…by about 2.5 percent. In manufacturing…the benefits share was 18.5 percent and job losses topped 18 percent.” [Emphasis in original.]

This picture was reinforced by a New York Times article based on “government data, industry surveys and interviews with employers big and small.” It said:

A relentless rise in the cost of employee health insurance has become a significant factor in the employment slump, as the labor market adds only a trickle of new jobs each month despite nearly three years of uninterrupted economic growth.… employers big and small…remain reluctant to hire full-time
employees because health insurance, which now costs the nation’s employers an average of about $3,000 a year for each worker, has become one of the fastest-growing costs.… Health premiums are sapping corporate balance sheets even more than the rising cost of energy.

Reacting to rising expenditures on insurance, corporate managements cut back on employee health benefits, triggering worker unrest. Consider the five-month strike against supermarket chains in Southern California—the longest in the industry’s history. It left about 60,000 union workers jobless, and it seriously hurt the owners as well. The central issue—in a state where half of all personal
bankruptcies are related to medical bills—was the demand by Safeway,Kroger and Albertsons that members of the United Food and Commercial Workers (UFCW) union pay much more for health benefits. The settlement, reached last February, sent a grim message to grocery workers everywhere.

The strike “would not have occurred if we had a system of universal healthcare coverage,” Greg Denier, assistant to the international president of the UFCW, told me. “All of our strikes in the past decade have occurred because of the absence of universal healthcare.” Moreover, universal health coverage would have narrowed the wide gap in operating costs between the unionized chains and nonunion competitors, particularly 800-pound gorilla Wal-Mart. Unlike the chains, the world’s biggest retailer charges so much for miserly health insurance that more than 60 percent of its poorly paid employees (averaging $8 an hour) don’t buy it. Denier saw the strike as a symptom of “the slow-motion collapse of the employment-based healthcare system.”

Lawyer Harry Burton represented Safeway and Giant Food in subsequent negotiations with the UFCW in the Washington, DC, region. Speaking “as an individual,” he essentially agreed with Denier. Universal health insurance would have “a profound effect” not just on the supermarket industry but “on nearly all collective bargaining,” he told me. Nonunion companies “virtually never” provide healthcare of the same quality as that provided by unionized competitors, thus creating “a vast disparity in costs.” That’s why a tax-supported national system would result in “a leveling of the playing field.” I asked Burton what explains the resistance or indifference of employers to universal health insurance. “Very frequently it’s ideology,” he replied.

Business leaders worship marketplace ideology “almost like religion,” says Raymond Werntz, who for nearly thirty years ran healthcare programs for Whitman Corporation, a Chicago-based multinational holding company. “It’s emotional.” In 1999 Werntz became the first president of the Consumer Health Education Council in Washington, a program of the Employee Benefit Research Institute, a nonprofit, nonpartisan group. He saw it as his mission to try to persuade employers to face the “huge, huge” issue of the uninsured because, he told me, “business has to be involved with the solution.” The problem that emerged was its “unwillingness to even think about a solution.”

Last year, after funding ran out, a disappointed Werntz became the council’s last and only president. Publicly financed universal health insurance comes in different forms. For Americans, however, none should hold more interest than
single-payer. It’s “one and the same thing” as Medicare for everybody, Werntz told me. Does the Corporate America that’s happy with Medicare understand this? I asked. “It’s a dialogue that hasn’t happened yet,” he replied. “My life for four years was trying to get business people in a room with single-payer people. I couldn’t do it.” CEOs of large corporations see it as something “that smacks of
socialism,” Werntz said, and therefore as “heresy.”

Somehow, they don’t see Medicare as heresy. Yet it’s largely why the tax-financed share of US health spending is “the highest in the world,” according to Drs. Steffie Woolhandler and David Himmelstein, associate professors at Harvard Medical School and founders of Physicians for a National Health Program. Writing in the July/August 2002 issue of Health Affairs , they put the share at 59.8 percent. No
wonder: Federal tax revenues pay for Medicare, Medicaid and the medical-care systems for the military, the Veterans Administration, federal employees and Congress; income-, sales- and property-tax revenues buy coverage for state and local public employees. Taxation also hugely subsidizes health insurance while benefiting mostly “the affluent,” the authors noted.

In 1991 the GAO made a stark finding regarding single-payer’s benefits: “If the universal coverage and single-payer features of the Canadian system [had been] applied in the United States” in that year, “the savings in administrative costs”—$66.9 billion—”would have been more than enough to finance insurance coverage for the millions of Americans who are currently uninsured,” the GAO said in a
report. The $3 billion left over “would be enough…to permit a reduction, or possibly even the elimination, of copayments and deductibles.”

Early this year, a comprehensive study published in the International Journal of Health Services reached this stunning conclusion: “The United States wastes more on health-care bureaucracy than it would cost to provide health care to all its uninsured.” The authors, Woolhandler, Himmelstein and Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group, went on to write: “Administrative expenses will consume at least $399.4 billion of a total health expenditure of $1,660.5 billion in 2003. Streamlining administrative overhead to Canadian levels would save approximately $286 billion in 2002, $6,940 for each of the 41.2 million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage.”

Canada has had a single-payer system for more than thirty years. (Australia, Denmark, Finland, Iceland, Sweden and Taiwan also have one.) American executives who have run Canadian subsidiaries see it as a business boon. Take General Motors. In 2003 its costs of building a midsize car in Canada were $1,40 less than building the identical car in the United States (the comparable figures for DaimlerChrysler and Ford were $1,300 and $1,200). Such savings are no mystery. Canadian companies pay far less in taxes for health coverage for everyone than the premiums they would pay under the US system to provide their employees with comparable benefits.

Highly placed Canadian business executives affirm that single-payer nurtures free enterprise. A. Charles Baillie, while chairman and CEO of Toronto Dominion Bank, one of Canada’s six largest, hailed it in 1999 as “an economic asset, not a burden.” He told the Vancouver Board of Trade, “In an era of globalization, we need every competitive and comparative advantage we have. And the fundamentals of our health care system are one of those advantages.” He added: “The fact is, the free market…cannot work in the context of universal health care. While health care could be purchased like any other form of insurance…the risk and resource equation will always be such that, in some cases, demand will not be matched by supply. In other words, some people will always be left out.” (A recent report by the World Bank ranked welfare states like Denmark, Finland and Sweden high in international competitiveness. An author of the study said, “Social protection is good for business, it takes the burden off of businesses for health care costs.”)

In 2002, top executives of the Big Three automakers’ Canadian units joined Basil (Buzz) Hargrove, president of the Canadian Auto Workers (CAW) union, in signing a “Joint Letter on Publicly Funded Health Care.” At a press conference with Hargrove, Michael Grimaldi, president and general manager of GM Canada and a GM vice president, called single-payer “a strategic advantage for Canada.” The joint letter, also signed by Ford’s and DaimlerChrysler’s presidents and CEOs, Alain Batty and Ed Brust, said that while providing “essential and affordable healthcare services for all,” single-payer “significantly reduces total labour costs…compared to the cost of equivalent private insurance services purchased by US-based automakers” and “has been an important ingredient” in the success of Canada’s “most important export industry.” The Toronto Star explained how the CAW used “credible corporate data” to quantify “the competitive advantage that [single-payer] provides to the Canadian auto industry. The union compared the hourly labour costs of vehicle assembly in Canada and the United States. The Canadian rate, including wages, benefits and payroll taxes, was $29.90 per hour. The American rate was $45.60. (All figures are in US dollars.) Healthcare
accounted for more than a quarter of the difference. It saved Canadian employers $4 per hour per worker.” Monthly health-coverage costs for Canadian employers average about $50, mostly for items such as eyeglasses and orthopedic shoes; health-insurance costs for US employers average $552, the Washington Post has reported.

“The rising cost of health benefits is the biggest issue on our plate that we can’t solve,” Ford CEO William Clay Ford told a 2003 conference of Michigan business executives. “Healthcare is out of control—it’s a system that’s broken.” Last year the company spent $3.2 billion on healthcare for 560,000 employees and their dependents and surviving spouses, or more than six times net profits of $495
million. William Ford urged a national solution and assigned vice,chairman Allan Gilmour to craft a proposal. Early this year Gilmour told fellow industry executives that high healthcare costs have “created a competitive gap that’s driving investment decisions away from the US.” He told a subsequent investment conference, “We’re going to have to have a national solution,” only to add, “That national solution does not mean, necessarily, national healthcare.”
Why not? He didn’t say.

After Jack Smith, president and general manager of GM Canada, became president and CEO of the parent company, an ad in the New York Times placed by single-payer advocates in 1994 quoted him as saying, “I personally favor single-payer.” Now, however, GM “does not support” it, spokesperson Doris Powers told me. Because? “Much has changed in health care since Smith…made statements about universal, single-payer healthcare.” What’s changed? She didn’t say.

A General Motors that hugs single-payer in Canada would seem to have compelling reasons to hug it here. GM covers healthcare costs for 1.1 million Americans. Last year’s bill was $4.8 billion—$1 billion more than earnings. In its third-quarter report the company reduced its 2004 earnings forecast because rising US healthcare costs were hurting profits. GM’s projected costs for providing healthcare benefits to current and future retirees is $63 billion, a burden immensely heavier than is carried by competitors based in universal-coverage countries, the New York Times reported in September. Yet, as the Detroit Free Press has noted, GM “has set aside less than $10 billion for that obligation.”

In 2001 GM was reeling from a prescription-drug bill up to 22 percent above 2000’s $1.1 billion. “Prescription drugs are the fastest-growing part of GM’s health-care costs, accounting for more than 25 percent of its total medical spending last year,” Newsweek reported. GM was “seeing red” because in 2000 it had spent $52 million just for Prilosec, a brand-name ulcer medicine. “That is millions more than GM executives believe they should have spent,” the magazine said. “They blame much of the extra cost on savvy marketing by Prilosec’s maker AstraZeneca.” GM is fighting back with an “aggressive plan to curb drug spending,” Newsweek continued. “Point man” James Cubbin “has been taking his case to senior executives at some of the nation’s largest drug makers, including AstraZeneca.”

But Newsweek— and Powers—missed an embarrassing part of the story. AstraZeneca chairman Percy Barnevik joined GM’s board in 1996, while Smith was GM’s chairman. Pfizer executive vice president Karen Katen followed in 1997, and the noses of both of these price-gouging drug companies are still in GM’s tent. Surprise: The pharmaceutical houses “aren’t backing down,” Newsweek said. Rather than going hat in hand to pharmaceutical executives, Canada uses single-payer’s price controls to cap drug prices. In two other universal-coverage countries, Australia and New Zealand, pharmacies charge 20 percent to 30 percent less than in Canada, the Wall Street Journal reported in July.

Unlike GM and Ford, DaimlerChrysler supports single-payer. “A lot of people think a single-payer system is better,” vice president Thomas Hadrych told the Washington Post . Since 1990 Chrysler—and DaimlerChrysler after the merger—has regularly endorsed it, in a letter appended to its contracts with the United Automobile Workers.

No matter how urgently needed, no matter how common-sensical, no matter how much bottom lines would be fattened, single-payer or other fundamental healthcare reforms stall unless backed by the business organizations that govern the government. The Clinton Administration learned this to its sorrow after proposing its complex, comprehensive plan. Business organizations “effectively killed the bill,” Walter Maher, former vice president for public policy of DaimlerChrysler, wrote last year in the American Journal of Public Health . The bill aroused formidable opposition from businesses such as fast-food chains like McDonald’s. It mostly hired young people, worked them less than full time, paid them little and provided scant if any health coverage. Of the PepsiCo chains’ hourly employees, a survey indicated, 71 percent were covered by someone else’s health insurance. If that someone was a parent employed by, say, an automaker facing global competition, the manufacturer was effectively subsidizing chains that had no such competition. Free-riding defeated a primary goal of the bill, which was to spread healthcare costs throughout the economy by letting no employers escape paying their fair share.

The bill received a big boost when the US Chamber of Commerce and the National Association of Manufacturers (NAM) let pragmatism trump ideology and endorsed it. And the mighty Business Roundtable (BRT), an association of 150 CEOs of the country’s biggest corporations, with multitrillion-dollar revenues, was “at least prepared not to oppose” the mandate, Maher said in the article.

But insurers and other businesses that profited from preserving the healthcare status quo exerted fierce counterpressures. The Chamber “suddenly reversed course and totally rejected the Clinton Plan,” Maher wrote. The NAM abruptly withdrew its endorsement six weeks after granting it. At the BRT several politically powerful members, including the CEOs of eight major and a few lesser pharmaceutical manufacturers, and of a dozen insurers and healthcare providers, opposed the bill. It got only a single vote—Chrysler’s, Maher told me. “It’s definitely fair to say that CEOs are very reluctant to take unpopular positions against their colleagues in the BRT,” he added. “If a huge majority of them are staunch conservatives who have no interest in health reform, or in using the government to control costs, or to expand coverage, or even to moderate health costs using regulatory tools, it’ll be a rare CEO who will want to take on his CEO buddies. That’s absolutely true.”

Today, BRT executive director Patricia Hanahan Engman contends that”public financing cannot provide the same level of quality doctors, hospitals and prescription drugs generated by the competition inherent in the private market.” She should tell that to GM president and CEO G. Richard Wagoner Jr. Judged by sixteen top health indicators, he said in June, the United States ranks twelfth among thirteen industrialized countries. “It will be a cold day in hell
when the BRT leads the charge for universal health coverage in the United States,” Maher told me.

If the Democrats win the White House and take control of Congress, John Kerry could pass his employer-based healthcare plan, which calls for expanding coverage to nearly 95 percent of Americans, including all children, and for a federal insurance pool that would pay 75 percent of “catastrophic” illness bills. Crucial elements might survive even if the GOP continues to control the House—mainly
because of forceful backing from pragmatic business leaders. For example, the Chamber of Commerce signed on early to Kerry’s pool idea, calling it “a seed for bipartisan reform.” In late October the New York Times reported that the Chamber was acclaiming the idea as “a worthy concept, an excellent use of federal tax dollars,” while some Senate Republicans are pushing it, and “lawmakers and lobbyists say that regardless of who wins the presidential election, Congress will soon take up the idea.” To be sure, Kerry’s scheme may face attacks by the usual suspects and the lawmakers they buy. One influential critic, the National Business Group on Health, has more than 200 members, including at least a dozen drug and medical-device manufacturers plus three dozen healthcare providers and insurers. A Wal-Mart vice president sits on its board.

Advocating universal health coverage while the GOP controls the White House and Congress would be “tilting at windmills,” DaimlerChrysler’s Dennis Fitzgibbons told me. Maher said any industry subject to government regulation “has got to be concerned about irritating the regulator,” meaning the Bush Administration. A single-payer reform proposal, by seeking to eliminate the insurance industry, he warned in his article, would make it and many other businesses “instant and
unnecessary opponents.” He recommends other forms of tax-financed universal health coverage that would use the industry. An example would be a system in which employer/employee payroll taxes would finance coverage for the working population, with employees offered several choices of health plans, as the Federal Employees Health Benefits Plan does. A Medicare equivalent would provide for the elderly and nonworking population.

“I don’t believe [single-payer] will be achievable in my lifetime,” says Ron Pollack, executive director of Families USA. Ideologues “will never support it.” Industries heavily invested in the present system “will spend every last dollar to stop it.” He recognizes that on “a blank slate,” employer-based coverage “absolutely” makes no sense. But “in terms of political feasibility,” trying to dismantle the present system would make matters “much worse,” he told me. “The most important thing is the achievement of affordable, high-quality health coverage for everybody.” To him, the crucial question is: “At what point are we willing to say that there’s a higher principle in truly moving toward universal coverage than in knocking our heads against a stone wall, in absolute frustration about a methodology [single-payer] that is not going to be achievable in our lifetime?”

Surely in a Republican Washington the prospects for publicly financed universal health insurance are remote. But Washington isn’t everywhere. Deborah Richter, a Vermont physician, believes it could still be enacted in every state. As president of Vermont Health Care for All, she’s been campaigning to that end in her own state for five years, with impressive results. Universal access to affordable, high-quality healthcare should be conceived “as a public good, as are roads, education, and police and fire protection,” she says. Making it “a practical issue works. Trying to win support for it by making it a moral issue never works.” By resisting the merger of practicality with morality that universal health care embodies, Corporate America is blowing a supreme opportunity to do well by doing good. Enlightened self-interest this is not.

Public Opinion of Consumer-Driven Plans

What’s Important In A Health Plan?
Kaiser Family Foundation
Health Poll Report - September/October 2004

Which one of the following do you think is the MOST important reason to have health insurance?

71% - To protect against high medical bills
25% - To pay for everyday health care expenses
03% - Don’t know

Catastrophic Coverage: Opinions

Suppose you heard about a type of insurance plan that only starts paying once you (and your family) have paid ($2,000/$5,000) of medical expenses out of your pocket. After that, it would cover medical expenses like traditional insurance, requiring you to pay some co-payments each time you use services. The monthly premium for the plan would be less than half of what you would pay for a typical comprehensive health insurance policy.

Would you have a favorable or unfavorable opinion about this type of health plan?

56% - Very unfavorable
21% - Somewhat unfavorable
13% - Somewhat favorable
05% - Very favorable

Would you feel well protected, or would you feel vulnerable to high medical bills with this type of health plan?

79% - Vulnerable
16% - Well protected
05% - Don’t know

Consumer-Driven Plans: Opinions

(Asked of those with employer-sponsored health insurance) There is a new type of health plan that some employers are considering. It works like this: your employer pays for a health plan that only starts to pay after you have spent ($2,000/$4,000) in medical expenses. They also put ($1,000/$2,000) in an account you can use for medical costs. If your medical expenses are more than ($1,000/$2,000), you have to pay with your own money until you hit the ($2,000/$4,000) limit.

Would you have a favorable or unfavorable opinion about this type of health plan?

52% - Very unfavorable
21% - Somewhat unfavorable
16% - Somewhat favorable
06% - Very favorable
05% - Don’t know

Would you feel well protected, or would you feel vulnerable to high medical bills with this type of health plan?

78% - Vulnerable
18% - Well protected
05% - Don’t know

And by political party and ideology - unfavorable opinion of these consumer-driven plans:

67% of Republicans
74% of Independents
78% of Democrats

68% of Conservatives
70% of Moderates
79% of Liberals

http://www.kff.org/healthpollreport/Oct_2004/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=48477

Comment: The proponents of consumer-driven health coverage have been successful in persuading the public to parrot their rhetoric that health insurance should not be used to pay for everyday health care expenses, but that the purpose is to protect against high medical bills. So the public has bought the rhetoric, but do they really believe it?

Much more significant in this poll are the responses of the public when asked about proposals that would fund everyday expenses out-of-pocket or through personal accounts. It is very clear that the overwhelming majority correctly perceive that these proposals would leave them vulnerable to high medical bills.

Other polls have repeatedly confirmed that the number one health care concern for most Americans is affordability, whether that be for insurance or for actual health care.

It is fascinating to note that this issue is not partisan. Liberals and conservatives agree that we want affordable health care. The single payer model would accomplish this. Are we ready to sit down together to begin seriously addressing the real policy issues behind reform? Or are the conservatives going to stubbornly watch their own care become less and less affordable merely to avoid admitting that our government really can be an effective partner in health care?

The government already funds 60% of our health care (when tax incentives are included). Isn’t it time to demand accountability for our public health care investment? Isn’t accountability a goal of conservatives with which we all can agree?

National health insurance policy law by year-end

National health insurance policy law by year-end
By Hani M. Bathish
31 October 2004

DUBAI ” The National Health Insurance Policy Law could be on the books by the end of the year, as the draft of the proposed law has already been submitted, an official from the UAE Ministry of Health has confirmed but stressed that the National Health Insurance Authority, the body that would administer the national health insurance scheme, will take a little longer to set up and could be ready by mid-2005.

Khaleej Times reported earlier this year on the formation of a committee of five experts and MoH officials that will determine the shape and scope of the proposed National Health Insurance Scheme. The committee is planning to meet in the near future although no date has been set for that meeting that could be held after Eid Al Fitr.

The committee is focused on making sure that the low-paid expatriate workers are not denied access to health care, and that access to health care is not linked to the ability to pay for medical treatment.

Earlier this year Hassan Ahmad Alkeem, Undersecretary of the MoH, said that the much-awaited health insurance scheme would be implemented by the end of the year. This now seems far-fetched as the committee balks at the amount of work left to be done.

The National Health Insurance Authority (NHIA), will be an independent health authority headed by the UAE Minister of Health, Hamad Abdel Rahman Al Midfa, and set up to supervise the health care facilities of the ministry, the delivery of medical services to the general public and the management of national health care spending.

Everyone in the health care industry would agree that the existing public health care system is both inadequate and overburdened, but the fact remains that there are many who doubt the feasibility of setting up the health insurance scheme by the end of this year, among these doubters are some in the insurance industry.

Health insurance will be compulsory for expatriates working and residing in the UAE, just as health cards are today. One of the suggested methods of financing the scheme is a two per cent payroll deduction from employees, to be matched by employers and the government. Sources have said this method of funding would generate around Dh1.2 billion in annual revenues, sufficient income to support the much-needed improvements to the public health infrastructure.