PNHP

AHIP & BCBSA support guaranteed issue and individual mandate

Archives for 2008

AHIP & BCBSA support guaranteed issue and individual mandate

Health Plans Propose Guaranteed Coverage for Pre-Existing Conditions and Individual Coverage Mandate

AHIP (America’s Health Insurance Plans)
November 19, 2008

Summary of AHIP’s Proposal to Guarantee Coverage for Pre-existing Conditions and Promote Affordability in the Individual Insurance Market:

* Guarantee-issue coverage with no pre-existing condition exclusions;

* Establish an individual coverage requirement with an insurance coverage verification system, an automatic enrollment process and effective enforcement of the requirement that all individuals purchase and maintain coverage;

* Promote affordability by: providing refundable, advanceable tax credits for moderate-income individuals and working families; and promoting tax equity whether coverage is obtained through an employer or the individual market; and

* Ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.

http://www.ahip.org/content/pressrelease.aspx?docid=25068

And…

BCBSA Announces Support for Individual Mandate Coupled with a Requirement for Insurers to Offer Coverage to All

BlueCross BlueShield Association (BCBSA)
November 19, 2008

To assure truly meaningful reform, the Blue Cross and Blue Shield Association (BCBSA) and the 39 member Blue Cross and Blue Shield companies today announced support for every individual being required to have coverage and all insurers being required to accept everyone regardless of their health status.

http://www.bcbs.com/news/bcbsa/bcbsa-announces-support-for.html

Comment:

By Don McCanne, MD

If anyone has any remaining doubt that comprehensive reform is close at hand, just look at the response of the private insurance industry. AHIP, representing 1,300 insurance companies, and BlueCross BlueShield Association, insuring over 100 million individuals, in simultaneous press releases have confirmed that they understand that, if they want to continue to insure the majority of Americans, they must abandon their current business model and come to the table with policies that work. Policies that work means that everyone must be included, and that risk must be distributed in an equitable manner, based on ability to pay.

So what is their current business model that no longer works? They have been successful in limiting their exposure to the very large numbers of us who are relatively healthful: the healthy workforce, their young healthy families, and the healthy sector of the individual insurance market. But health care costs are now so high that the premiums that must be charged for these healthy risk pools are no longer affordable for the majority of us.

The industry’s response was to reduce benefits thereby reducing the upward pressure on premiums, but that has resulted in the rapidly growing epidemic of underinsurance. As a result, health care is now often unaffordable even for those who do have insurance. Also, in response to high premiums and mediocre coverage the numbers of uninsured continue to rise.

The private insurance industry has been trying to ride this out, but no more. Their hand is being forced by the political tidal wave that is sweeping over our health care system with the demand for reform that works for all of us.

They understand that in a truly universal system they must guarantee coverage for everyone regardless of preexisting conditions. Since that would push premiums up, they know that they must add larger numbers of healthy individuals to dilute the risk in their pools. An obvious source is the large numbers of young, healthy individuals who are uninsured. But the only way those individuals would pay the high premiums would be by forcing them to participate. Thus an individual mandate must be coupled with guaranteed issue.

The industry pretends that an individual mandate with guaranteed issue is all that they need to be major players, but they are reticent on revealing the most crucial barrier that they face. Although premiums for private plans are already too high for average-income individuals to afford, they must reverse the innovations that have led to underinsurance. Obviously that will significantly increase premiums. Also, since they currently sell to mostly healthy individuals, adding those with preexisting disorders will result in even higher premiums.

What to do, what to do? The AHIP release gives us a couple of hints.

Those supporting universal coverage through private health plans have long conceded that tax credits (or vouchers) must be used to assist low-income individuals with the purchase of their plans. In their press release, AHIP now states that we must use “refundable, advanceable tax credits for moderate-income individuals and working families.” Finally, the industry explicitly concedes that most of us can no longer afford to purchase their health plans. So who is going to help? The taxpayers. Gee, isn’t that us?

The other problem is how are they going to pay for the high-risk individuals who now must be covered? Their solution is somewhat more cryptic. They are going to “ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.” “Premium stability” means that other sources will be paying the higher costs of the higher-risk individuals. What other sources? They propose “Guarantee Access Plans” which are “loosely modeled on state high-risk pools.” Oops. The taxpayers – us – again.

Think about it. The private insurance industry has just the solution for us, but only if we agree to foot the bill for those who actually need health care, while they continue to collect large premiums to pay for their egregiously wasteful administrative excesses.

Their proposal is to shift the real costs of health care to the taxpayer. They are right. We need to establish a universal risk pool and fund it equitably based on ability to pay. The only sensible way to do that is through a single payer national health program. Why would we want to implant on our health care financing system the cancer of private health plans?

AHIP & BCBSA support guaranteed issue and individual mandate

Health Plans Propose Guaranteed Coverage for Pre-Existing Conditions and Individual Coverage Mandate

AHIP (America’s Health Insurance Plans)
November 19, 2008

Summary of AHIP’s Proposal to Guarantee Coverage for Pre-existing Conditions and Promote Affordability in the Individual Insurance Market:

* Guarantee-issue coverage with no pre-existing condition exclusions;

* Establish an individual coverage requirement with an insurance coverage verification system, an automatic enrollment process and effective enforcement of the requirement that all individuals purchase and maintain coverage;

* Promote affordability by: providing refundable, advanceable tax credits for moderate-income individuals and working families; and promoting tax equity whether coverage is obtained through an employer or the individual market; and

* Ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.

http://www.ahip.org/content/pressrelease.aspx?docid=25068

And…

BCBSA Announces Support for Individual Mandate Coupled with a Requirement for Insurers to Offer Coverage to All

BlueCross BlueShield Association (BCBSA)
November 19, 2008

To assure truly meaningful reform, the Blue Cross and Blue Shield Association (BCBSA) and the 39 member Blue Cross and Blue Shield companies today announced support for every individual being required to have coverage and all insurers being required to accept everyone regardless of their health status.

http://www.bcbs.com/news/bcbsa/bcbsa-announces-support-for.html

Comment:

By Don McCanne, MD

If anyone has any remaining doubt that comprehensive reform is close at hand, just look at the response of the private insurance industry. AHIP, representing 1,300 insurance companies, and BlueCross BlueShield Association, insuring over 100 million individuals, in simultaneous press releases have confirmed that they understand that, if they want to continue to insure the majority of Americans, they must abandon their current business model and come to the table with policies that work. Policies that work means that everyone must be included, and that risk must be distributed in an equitable manner, based on ability to pay.

So what is their current business model that no longer works? They have been successful in limiting their exposure to the very large numbers of us who are relatively healthful: the healthy workforce, their young healthy families, and the healthy sector of the individual insurance market. But health care costs are now so high that the premiums that must be charged for these healthy risk pools are no longer affordable for the majority of us.

The industry’s response was to reduce benefits thereby reducing the upward pressure on premiums, but that has resulted in the rapidly growing epidemic of underinsurance. As a result, health care is now often unaffordable even for those who do have insurance. Also, in response to high premiums and mediocre coverage the numbers of uninsured continue to rise.

The private insurance industry has been trying to ride this out, but no more. Their hand is being forced by the political tidal wave that is sweeping over our health care system with the demand for reform that works for all of us.

They understand that in a truly universal system they must guarantee coverage for everyone regardless of preexisting conditions. Since that would push premiums up, they know that they must add larger numbers of healthy individuals to dilute the risk in their pools. An obvious source is the large numbers of young, healthy individuals who are uninsured. But the only way those individuals would pay the high premiums would be by forcing them to participate. Thus an individual mandate must be coupled with guaranteed issue.

The industry pretends that an individual mandate with guaranteed issue is all that they need to be major players, but they are reticent on revealing the most crucial barrier that they face. Although premiums for private plans are already too high for average-income individuals to afford, they must reverse the innovations that have led to underinsurance. Obviously that will significantly increase premiums. Also, since they currently sell to mostly healthy individuals, adding those with preexisting disorders will result in even higher premiums.

What to do, what to do? The AHIP release gives us a couple of hints.

Those supporting universal coverage through private health plans have long conceded that tax credits (or vouchers) must be used to assist low-income individuals with the purchase of their plans. In their press release, AHIP now states that we must use “refundable, advanceable tax credits for moderate-income individuals and working families.” Finally, the industry explicitly concedes that most of us can no longer afford to purchase their health plans. So who is going to help? The taxpayers. Gee, isn’t that us?

The other problem is how are they going to pay for the high-risk individuals who now must be covered? Their solution is somewhat more cryptic. They are going to “ensure premium stability for those with existing coverage through a broadly funded reimbursement mechanism that spreads costs for the highest-risk individuals.” “Premium stability” means that other sources will be paying the higher costs of the higher-risk individuals. What other sources? They propose “Guarantee Access Plans” which are “loosely modeled on state high-risk pools.” Oops. The taxpayers – us – again.

Think about it. The private insurance industry has just the solution for us, but only if we agree to foot the bill for those who actually need health care, while they continue to collect large premiums to pay for their egregiously wasteful administrative excesses.

Their proposal is to shift the real costs of health care to the taxpayer. They are right. We need to establish a universal risk pool and fund it equitably based on ability to pay. The only sensible way to do that is through a single payer national health program. Why would we want to implant on our health care financing system the cancer of private health plans?

HHS Secretary-elect Daschle's plan for reform

Daschle Nominated to Human Services Cabinet Post

By Helene Cooper
The New York Times
November 19, 2008
President-elect Barack Obama has offered the nomination of Secretary of Health and Human Services to Tom Daschle of South Dakota, the former Democratic Senate leader who was an early supporter of Mr. Obama’s run for the presidency.
Democratic officials said that Mr. Daschle has accepted the nomination.
Mr. Obama’s transition team announced on Wednesday that Mr. Daschle will also oversee Mr. Obama’s health policy working group to develop a health care plan, which could take care of what his friends say was one of Mr. Daschle’s conditions for considering the HHS post. He was concerned that he not just be the head of a huge bureaucracy but a chief player on the subject he has literally written a book on.
Mr. Daschle’s book about health policy “Critical: What We Can Do About the Health-Care Crisis” came out in February. In it he proposes creating a Federal Health Board, similar to the Federal Reserve System, and the merging of employers’ plans, Medicaid and Medicare with an expanded federal employee health benefits program that would provide universal coverage.
http://thecaucus.blogs.nytimes.com/2008/11/19/daschle-takes-human-services-cabinet-post/?hp

And…

Critical: What We Can Do About the Health-Care Crisis

By Senator Tom Daschle with Scott S. Greenberger and Jeanne M. Lambrew
Macmillan
Daschle’s solution lies in the Federal Reserve Board, which has overseen the equally complicated financial system with great success. A Fed-like health board would offer a public framework within which a private health-care system can operate more effectively and efficiently — insulated from political pressure yet accountable to elected officials and the American people. Daschle argues that this independent board would create a single standard of care and exert tremendous influence on every other provider and payer, even those in the private sector.
http://us.macmillan.com/critical

Today’s quote leads to a question: Can Sen. Daschle’s Federal Health Board do for the crisis in health care what the Federal Reserve Board has done for nation’s financial crisis?
Stay tuned.

PNHP letter to Sen. Baucus, Senate Finance Committee

November 18, 2008

The Honorable Max Baucus
Chairman, Finance Committee
U.S. Senate
Hart Senate Office Building
Washington, DC 20510

Dear Chairman Baucus,

Physicians for a National Health Program respectfully requests an opportunity for one or more of our members to testify about the merits of single-payer national health insurance (as embodied in the U.S. National Health Insurance Act, H.R. 676, which currently has the support of over 90 member of Congress) at the Senate Finance Committee’s hearings titled “Healthcare Reform: An Economic Perspective.”

Single-payer health reform, sometimes characterized as an improved “Medicare for All,” is the only reform model that offers $400 billion in annual savings in administrative costs. It is the only approach that contains effective cost-containment provisions, such as bulk purchasing and global budgeting. Such economies would allow for expanding health coverage to everyone — with no co-pays or deductibles — with no overall increase in health care spending.

The single-payer model is the only fiscally prudent proposal available, an especially important consideration at a time of economic distress. By basing itself (and improving upon) Medicare, it presents itself as a uniquely American way of guaranteeing care to all who need it. Such an approach has proven its effectiveness.

With a single-payer national health insurance program we can assure lifelong, high quality, comprehensive and affordable coverage for everyone. Such a program will lift the heavy burden of crushing medical expenses off the shoulders of our population, expenses that often lead to personal bankruptcy. And we can save lives: the Institute of Medicine estimates that more than 18,000 Americans die each year from lack of health insurance.

From the standpoint of what benefits our patients, single payer is the health policy model that best reflects their needs and values.

Support for single payer is extensive. In a peer-reviewed statistical study in the Annals of Internal Medicine, 59 percent of U.S. physicians said they would support government action to establish national health insurance. In a recent Associated Press poll, 65 percent of the respondents said, “The United State should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxes.”

In addition, over 480 labor organizations, including 39 state federations of the AFL-CIO, have endorsed single payer legislation, as have numerous professional associations, city and state governments, and religious denominations.

We therefore expect that single-payer proponents will be invited to testify before the Committee and we look forward to your affirmative response. You can telephone me at (312) 782-6006 or reach me via e-mail at info@pnhp.org.

Sincerely,

Quentin Young, MD, MACP
National Coordinator
Physicians for a National Health Program

cc: Senate Finance Committee members

HHS Secretary-elect Daschle's plan for reform

Daschle Nominated to Human Services Cabinet Post

By Helene Cooper
The New York Times
November 19, 2008

President-elect Barack Obama has offered the nomination of Secretary of Health and Human Services to Tom Daschle of South Dakota, the former Democratic Senate leader who was an early supporter of Mr. Obama’s run for the presidency.

Democratic officials said that Mr. Daschle has accepted the nomination.

Mr. Obama’s transition team announced on Wednesday that Mr. Daschle will also oversee Mr. Obama’s health policy working group to develop a health care plan, which could take care of what his friends say was one of Mr. Daschle’s conditions for considering the HHS post. He was concerned that he not just be the head of a huge bureaucracy but a chief player on the subject he has literally written a book on.

Mr. Daschle’s book about health policy “Critical: What We Can Do About the Health-Care Crisis” came out in February. In it he proposes creating a Federal Health Board, similar to the Federal Reserve System, and the merging of employers’ plans, Medicaid and Medicare with an expanded federal employee health benefits program that would provide universal coverage.

http://thecaucus.blogs.nytimes.com/2008/11/19/daschle-takes-human-services-cabinet-post/?hp

And…

Critical: What We Can Do About the Health-Care Crisis

By Senator Tom Daschle with Scott S. Greenberger and Jeanne M. Lambrew
Macmillan

Daschle’s solution lies in the Federal Reserve Board, which has overseen the equally complicated financial system with great success. A Fed-like health board would offer a public framework within which a private health-care system can operate more effectively and efficiently — insulated from political pressure yet accountable to elected officials and the American people. Daschle argues that this independent board would create a single standard of care and exert tremendous influence on every other provider and payer, even those in the private sector.

http://us.macmillan.com/critical

Comment:

By Don McCanne, MD

Today’s quote leads to a question: Can Sen. Daschle’s Federal Health Board do for the crisis in health care what the Federal Reserve Board has done for nation’s financial crisis?

Stay tuned.

A Senator's Health Plan

By Rose Ann DeMoro
New York Times
November 18, 2008

To the Editor:

Re “Senator Takes Initiative on Health Care” (news article, Nov. 12):

The proposal by Senator Max Baucus, Democrat of Montana, is a partial step in the right direction, most notably with his common-sense suggestion to expand Medicaid and Medicare, two publicly financed, mostly privately delivered programs.

Medicare has just a fraction of the bloated administrative costs of private insurance, which slices 30 percent off the top for profits and paperwork, much of it spent on denying needed care.

Unfortunately, the Baucus plan has several poison pills: it would force everyone not presently covered to buy private insurance, and revives the discredited McCain plan of taxing health benefits for many employees, which would push some workers from employer-sponsored coverage into the shark-infested private market.

Both steps would buttress and further enrich the health insurance industry, which hardly needs the help, and fail to solve the health care crisis.

Millions of Americans have found out the hard way that access to coverage is not the same as access to care. A better, more cost-effective approach would be to simply expand Medicare to cover everyone, the only real way to assure guaranteed health care for all.

Rose Ann DeMoro
Executive Director,
National Nurses Organizing Committee/California Nurses Association
Oakland, Calif., Nov. 14, 2008

HHS Secretary-elect Daschle’s plan for reform

Daschle Nominated to Human Services Cabinet Post

By Helene Cooper
The New York Times
November 19, 2008

President-elect Barack Obama has offered the nomination of Secretary of Health and Human Services to Tom Daschle of South Dakota, the former Democratic Senate leader who was an early supporter of Mr. Obama’s run for the presidency.

Democratic officials said that Mr. Daschle has accepted the nomination.

Mr. Obama’s transition team announced on Wednesday that Mr. Daschle will also oversee Mr. Obama’s health policy working group to develop a health care plan, which could take care of what his friends say was one of Mr. Daschle’s conditions for considering the HHS post. He was concerned that he not just be the head of a huge bureaucracy but a chief player on the subject he has literally written a book on.

Mr. Daschle’s book about health policy “Critical: What We Can Do About the Health-Care Crisis” came out in February. In it he proposes creating a Federal Health Board, similar to the Federal Reserve System, and the merging of employers’ plans, Medicaid and Medicare with an expanded federal employee health benefits program that would provide universal coverage.

http://thecaucus.blogs.nytimes.com/2008/11/19/daschle-takes-human-services-cabinet-post/?hp

And…

Critical: What We Can Do About the Health-Care Crisis

By Senator Tom Daschle with Scott S. Greenberger and Jeanne M. Lambrew
Macmillan

Daschle’s solution lies in the Federal Reserve Board, which has overseen the equally complicated financial system with great success. A Fed-like health board would offer a public framework within which a private health-care system can operate more effectively and efficiently — insulated from political pressure yet accountable to elected officials and the American people. Daschle argues that this independent board would create a single standard of care and exert tremendous influence on every other provider and payer, even those in the private sector.

http://us.macmillan.com/critical

Comment:

By Don McCanne, MD

Today’s quote leads to a question: Can Sen. Daschle’s Federal Health Board do for the crisis in health care what the Federal Reserve Board has done for nation’s financial crisis?

Stay tuned.

A Senator’s Health Plan

By Rose Ann DeMoro
New York Times
November 18, 2008

To the Editor:

Re “Senator Takes Initiative on Health Care” (news article, Nov. 12):

The proposal by Senator Max Baucus, Democrat of Montana, is a partial step in the right direction, most notably with his common-sense suggestion to expand Medicaid and Medicare, two publicly financed, mostly privately delivered programs.

Medicare has just a fraction of the bloated administrative costs of private insurance, which slices 30 percent off the top for profits and paperwork, much of it spent on denying needed care.

Unfortunately, the Baucus plan has several poison pills: it would force everyone not presently covered to buy private insurance, and revives the discredited McCain plan of taxing health benefits for many employees, which would push some workers from employer-sponsored coverage into the shark-infested private market.

Both steps would buttress and further enrich the health insurance industry, which hardly needs the help, and fail to solve the health care crisis.

Millions of Americans have found out the hard way that access to coverage is not the same as access to care. A better, more cost-effective approach would be to simply expand Medicare to cover everyone, the only real way to assure guaranteed health care for all.

Rose Ann DeMoro
Executive Director,
National Nurses Organizing Committee/California Nurses Association
Oakland, Calif., Nov. 14, 2008

The uninsured give but rarely receive transplants

Insurance Status of U.S. Organ Donors and Transplant Recipients: The Uninsured Give, but Rarely Receive

By Andrew A. Herring, Steffie Woolhandler, and David U. Himmelstein
International Journal of Health Services
Volume 38, Number 4
In September of 2005, one of us (Herring), then a third-year medical student, cared for a previously healthy 25-year-old uninsured day laborer who arrived at the emergency department with rapidly advancing idiopathic dilated cardiomyopathy. The patient was ultimately deemed unsuitable for cardiac transplantation. The decision on transplantation was driven, in part, by realistic concern about the patient’s inability to pay for long-term immunosuppressive therapy and to support himself during recovery. Absent such resources, the likelihood of a successful outcome is compromised. The clinicians caring for him faced a wrenching dilemma: deny the patient a transplant, or use a scarce organ for a patient with a reduced chance of success. He died of heart failure two weeks after his initial presentation. This tragedy inspired us to examine data on the participation of the uninsured in organ transplantation, both as recipients and as donors.
Abstract
Organ transplantation is an expensive, life-saving technology. Previous studies have found that few transplant recipients in the United States lack health insurance (in part because patients may become eligible for special coverage because of their disability and transplant teams vigorously advocate for their patients). Few data are available on the insurance status of U.S. organ donors. The authors analyzed the 2003 National Inpatient Sample (NIS), a nationally representative 20 percent sample of U.S. hospital stays, and identified incident organ donors and recipients using ICD-9-CM diagnosis and procedure codes. The NIS sample included 1,447 organ donors and 4,962 transplant recipients, equivalent after weighting to 6,517 donors and 23,656 recipients nationwide; 16.9 percent of organ donors but only 0.8 percent of transplant recipients were uninsured. In multivariate analysis, compared with other inpatients organ donors were much more likely to be uninsured (OR 3.41, 95% CI 2.81-4.15), whereas transplant recipients were less likely to lack coverage (OR 0.08, 95% CI 0.06-0.12). Many uninsured Americans donate organs, but they rarely receive them.
https://pnhp.org/organ_donors/Transplants.pdf

Because of the mismatch between the numbers of individuals who are candidates to receive organ transplants and the numbers of donors available, sometimes difficult decisions have to be made as to who will receive the transplants. As complex as these decisions are, it is a sad commentary that, in the United States, we add one additional complicating factor: Does the potential recipient have insurance?
It is reassuring to note that the dedicated transplant teams can sometimes break through this barrier through vigorous advocacy on behalf of their patients. But it is wrong that they should have to do that. And it is especially wrong that uninsured candidates may be unsuccessful in negotiating this barrier.
These life and death decisions are not based on a lack of money; we are already spending more than enough. Rather people are dying merely because of the way we allocate that money. A single payer national health program would remove money as a consideration and allow us to concentrate on the other moral and ethical factors that should determine who lives and who dies.
What a terrible decision to have to make. But let’s not make it based on ability to pay.

The uninsured give but rarely receive transplants

Insurance Status of U.S. Organ Donors and Transplant Recipients: The Uninsured Give, but Rarely Receive

By Andrew A. Herring, Steffie Woolhandler, and David U. Himmelstein
International Journal of Health Services
Volume 38, Number 4

In September of 2005, one of us (Herring), then a third-year medical student, cared for a previously healthy 25-year-old uninsured day laborer who arrived at the emergency department with rapidly advancing idiopathic dilated cardiomyopathy. The patient was ultimately deemed unsuitable for cardiac transplantation. The decision on transplantation was driven, in part, by realistic concern about the patient’s inability to pay for long-term immunosuppressive therapy and to support himself during recovery. Absent such resources, the likelihood of a successful outcome is compromised. The clinicians caring for him faced a wrenching dilemma: deny the patient a transplant, or use a scarce organ for a patient with a reduced chance of success. He died of heart failure two weeks after his initial presentation. This tragedy inspired us to examine data on the participation of the uninsured in organ transplantation, both as recipients and as donors.

Abstract

Organ transplantation is an expensive, life-saving technology. Previous studies have found that few transplant recipients in the United States lack health insurance (in part because patients may become eligible for special coverage because of their disability and transplant teams vigorously advocate for their patients). Few data are available on the insurance status of U.S. organ donors. The authors analyzed the 2003 National Inpatient Sample (NIS), a nationally representative 20 percent sample of U.S. hospital stays, and identified incident organ donors and recipients using ICD-9-CM diagnosis and procedure codes. The NIS sample included 1,447 organ donors and 4,962 transplant recipients, equivalent after weighting to 6,517 donors and 23,656 recipients nationwide; 16.9 percent of organ donors but only 0.8 percent of transplant recipients were uninsured. In multivariate analysis, compared with other inpatients organ donors were much more likely to be uninsured (OR 3.41, 95% CI 2.81-4.15), whereas transplant recipients were less likely to lack coverage (OR 0.08, 95% CI 0.06-0.12). Many uninsured Americans donate organs, but they rarely receive them.

https://pnhp.org/organ_donors/Transplants.pdf

Comment:

By Don McCanne, MD

Because of the mismatch between the numbers of individuals who are candidates to receive organ transplants and the numbers of donors available, sometimes difficult decisions have to be made as to who will receive the transplants. As complex as these decisions are, it is a sad commentary that, in the United States, we add one additional complicating factor: Does the potential recipient have insurance?

It is reassuring to note that the dedicated transplant teams can sometimes break through this barrier through vigorous advocacy on behalf of their patients. But it is wrong that they should have to do that. And it is especially wrong that uninsured candidates may be unsuccessful in negotiating this barrier.

These life and death decisions are not based on a lack of money; we are already spending more than enough. Rather people are dying merely because of the way we allocate that money. A single payer national health program would remove money as a consideration and allow us to concentrate on the other moral and ethical factors that should determine who lives and who dies.

What a terrible decision to have to make. But let’s not make it based on ability to pay.