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Vetting McCain's Health Plan

Archives for 2008

Vetting McCain's Health Plan

Tax credits would move people out of group plans and into individual policies where the benefits aren't as good

By Jane Bryant Quinn
Newsweek
October 13, 2008

If you think that “The Market” — whatever market — always works for the best, you’ll love John McCain’s version of health insurance reform. It uses the tax code to shove you toward individual policies (more “choice!”) and away from comprehensive, employer supported plans. The nonpartisan Tax Policy Center puts the cost of his proposed subsidies at $1.3 trillion over 10 years.

But a funny thing happens on the way to spending that much money. Almost all of the subsidy goes to people who have health insurance already, says Sherry Glied, a professor of health policy at Columbia University. The Tax Policy Center figures that, after 10 years, the plan cuts the number of uninsured by only 1 million, out of 45.7 million now. Barack Obama’s $1.6 trillion plan would take 34 million off the rolls of the uninsured.

McCain’s idea is pretty simple. Tax the value of employer-paid health insurance as part of your regular income (62 percent of the nonelderly are in these plans). In return, he’d give everyone a refundable tax credit–$2,500 for individuals, $5,000 for family coverage–to offset the cost of any health policy they choose. Here’s how the McCain plan falls out:

* Initially, most of the people in employer plans would get a bonus from the government. Their new tax credit would exceed the amount of extra taxes they owed. For the young and healthy, the bonus could be quite large. Older workers with health problems might get a minimal bonus but still do OK. Over the years, however, the value of the credit would be eroded by health care inflation, and your tax cost would rise.

* If you already buy your own health insurance, the tax credit would chop your premium cost by $2,500 or $5,000. The self-employed lose the deduction they get for health-insurance premiums but would generally still come out ahead (again, until inflation intervened).

* If you’re uninsured, the tax credit helps you purchase coverage. The only hitch–a big one–is that you have to be able to afford the premiums up front. The tax credit comes later. The government will send it to the insurance company, which will apply it to your account.

To see how much the McCain plan helps, I asked Scott Leavitt, president of the National Association of Health Underwriters, to price typical policies for healthy singles, couples and families in the Chicago area. It appears that the credit could pretty much cover the premium in your 20s and 30s, even early 40s, making it a good deal. At 55, however, a couple might pay more than $12,000–difficult for older people with modest incomes.

* The Tax Policy Center estimates that 20 million workers will leave the employer-based system, not always voluntarily. Midsize and smaller companies are likely to drop their plans and tell you to use the credit to buy a policy yourself.

* It’s a shock to move from group plans into the harsh world of individual insurance. You get “choices” (rah, rah). But the policies cost more and cover less than company plans do–especially for women, older people and those whose health is less than perfect.

That is, if you can find coverage at all. In 2006, the Commonwealth Fund studied working-age adults hunting for individual policies. One-fifth were charged more or rejected for health reasons. More than half found it hard or impossible to secure a policy they could afford.

Conservatives love health plans that throw more of the costs on you. When it’s hard to pay the bills, you see the doctor less. Through the “magic of the marketplace,” that’s supposed to slow the rate of increase in medical costs.

Friends, there’s zero evidence that that works. In the long run, tax credits will raise your costs without changing the game. And we still won’t have helped most of the uninsured.

With Reporter Associate: Temma Ehrenfeld

URL: http://www.newsweek.com/id/162335

Vetting McCain’s Health Plan

Tax credits would move people out of group plans and into individual policies where the benefits aren’t as good

By Jane Bryant Quinn
Newsweek
October 13, 2008

If you think that “The Market” — whatever market — always works for the best, you’ll love John McCain’s version of health insurance reform. It uses the tax code to shove you toward individual policies (more “choice!”) and away from comprehensive, employer supported plans. The nonpartisan Tax Policy Center puts the cost of his proposed subsidies at $1.3 trillion over 10 years.

But a funny thing happens on the way to spending that much money. Almost all of the subsidy goes to people who have health insurance already, says Sherry Glied, a professor of health policy at Columbia University. The Tax Policy Center figures that, after 10 years, the plan cuts the number of uninsured by only 1 million, out of 45.7 million now. Barack Obama’s $1.6 trillion plan would take 34 million off the rolls of the uninsured.

McCain’s idea is pretty simple. Tax the value of employer-paid health insurance as part of your regular income (62 percent of the nonelderly are in these plans). In return, he’d give everyone a refundable tax credit–$2,500 for individuals, $5,000 for family coverage–to offset the cost of any health policy they choose. Here’s how the McCain plan falls out:

* Initially, most of the people in employer plans would get a bonus from the government. Their new tax credit would exceed the amount of extra taxes they owed. For the young and healthy, the bonus could be quite large. Older workers with health problems might get a minimal bonus but still do OK. Over the years, however, the value of the credit would be eroded by health care inflation, and your tax cost would rise.

* If you already buy your own health insurance, the tax credit would chop your premium cost by $2,500 or $5,000. The self-employed lose the deduction they get for health-insurance premiums but would generally still come out ahead (again, until inflation intervened).

* If you’re uninsured, the tax credit helps you purchase coverage. The only hitch–a big one–is that you have to be able to afford the premiums up front. The tax credit comes later. The government will send it to the insurance company, which will apply it to your account.

To see how much the McCain plan helps, I asked Scott Leavitt, president of the National Association of Health Underwriters, to price typical policies for healthy singles, couples and families in the Chicago area. It appears that the credit could pretty much cover the premium in your 20s and 30s, even early 40s, making it a good deal. At 55, however, a couple might pay more than $12,000–difficult for older people with modest incomes.

* The Tax Policy Center estimates that 20 million workers will leave the employer-based system, not always voluntarily. Midsize and smaller companies are likely to drop their plans and tell you to use the credit to buy a policy yourself.

* It’s a shock to move from group plans into the harsh world of individual insurance. You get “choices” (rah, rah). But the policies cost more and cover less than company plans do–especially for women, older people and those whose health is less than perfect.

That is, if you can find coverage at all. In 2006, the Commonwealth Fund studied working-age adults hunting for individual policies. One-fifth were charged more or rejected for health reasons. More than half found it hard or impossible to secure a policy they could afford.

Conservatives love health plans that throw more of the costs on you. When it’s hard to pay the bills, you see the doctor less. Through the “magic of the marketplace,” that’s supposed to slow the rate of increase in medical costs.

Friends, there’s zero evidence that that works. In the long run, tax credits will raise your costs without changing the game. And we still won’t have helped most of the uninsured.

With Reporter Associate: Temma Ehrenfeld

URL: http://www.newsweek.com/id/162335

Lewin analysis of candidates' proposals

McCain and Obama Health Care Proposals: Cost and Coverage Compared

The Lewin Group
October 8, 2008

In this study, The Lewin Group estimated the cost and coverage impacts (for 2010-2019) of the health reform proposals introduced by Senators McCain and Obama. Our key findings are that the McCain proposal would reduce the number of uninsured from a projected number of 48.9 million people in 2010 by 21.1 million people if fully implemented in that year. The Obama plan would reduce the number of uninsured by 26.6 million people. The McCain proposal would result in a net increase in federal spending (i.e., net of offsets) of $2.05 trillion over the 2010 through 2019 period compared with a net federal cost of $1.17 trillion under the Obama plan over this same ten-year period.

The Candidates’ Proposals

The McCain proposal would expand coverage through private insurance and decrease regulation of health insurance markets. His plan would provide a refundable tax credit of $2,500 for single filers and $5,000 for families that have private health insurance from an employer or as an individual in the non-group market. Insurers would be permitted to sell insurance across state lines, thus sidestepping state minimum benefit and insurance rating regulations.

The McCain proposal would establish federally subsidized high-risk pools called the Guaranteed Access Program (GAP) to cover those denied coverage due to health status. The Campaign indicates that half of the losses under the GAP would be paid with an assessment on private insurance with the federal government providing the remaining half.

The Obama proposal would expand coverage through public and private insurance and increase federal regulation of insurance markets. His proposal would expand Medicaid eligibility to include all very low-income adults and would provide premium subsidies for people with low to moderate incomes. Insurers would be prohibited from denying coverage or setting insurance premiums on the basis of health status. Also, the Obama plan would provide small employers with a tax credit for the purchase of insurance and would create a federally subsidized reinsurance program to cover “catastrophic health” expenses in employer plans.

Senator Obama’s plan would also create a “National Exchange” offering a selection of private health insurance options comparable to those now offered to members of Congress and federal workers. The exchange would be open to individuals, the self-employed and small employers. In addition, the Obama proposal would create a new publicly-operated insurance program called the “National Plan” that would be available as an alternative to private coverage in the National Exchange.

Unlike the McCain plan, the Obama proposal would establish a minimum standard of covered benefits.

http://www.lewin.com/dyn/healthpolicies

Comment:

By Don McCanne, MD

The release of this report from The Lewin Group has provoked a debate on whether it accurately reflects the numbers of individuals that would gain coverage under the McCain and Obama proposals respectively. Although this debate is legitimate, it misses the most important point. We don’t really care how many people nominally have health insurance; we want to know whether or not people are protected from financial hardship should they need health care.

The McCain proposal aims to make premiums for private health plans affordable by deregulating the market. Premiums can be kept low by (1) creating a market of underinsurance products (limited benefits and greater cost sharing, especially through high deductibles), and by (2) insuring only low risk individuals who can pass medical underwriting standards.

The Lewin report makes the assumption that when the McCain plan is fully implemented in 2010 the number of individuals with private employer coverage will decrease from 157 million to 148 million. That level of decrease might be true at the beginning of the program, but incentives are likely to cause a further dramatic decline in employer-sponsored coverage. If an individual can obtain a very inexpensive plan in a deregulated market, and the government is going to provide a $2500/$5000 tax credit, why would an employer want to continue to offer an expensive comprehensive plan, and why would an employee pass up a pay increase offered by the employer for those who decline coverage?

Once a large number of healthy employees move into the individual market, the employer-sponsored plans will be subject to adverse selection. The spiraling costs of premiums will cause employers to terminate their plans, especially since a President McCain’s proposal would have opened up the individual market to plans with affordable premiums, albeit underinsurance plans.

Since the deregulated market insures only healthy individuals, the individuals who actually need health will have to look elsewhere for coverage. Sen. McCain understands this, and that is why he has proposed the Guaranteed Access Program (GAP) to insure these individuals with greater needs.

This is where there is a problem with defining the success of a reform proposal by the numbers of insured individuals. The very large number of individuals purchasing underinsurance plans are healthy, but most of the spending is on the smaller group with needs that will be forced to obtain coverage under GAP. The Lewin Group estimates that of those with chronic health conditions who are currently uninsured, only 24 percent would be covered by the McCain proposal. These are people who most desperately need coverage, yet three-fourths of them would remain uninsured.

How does McCain propose to pay the high costs of those who do make it into GAP? Half would be paid by federal subsidies (taxes), but the other half would be paid by assessments on individual private insurance plans. Suddenly the cheap premiums for these underinsurance products aren’t so cheap anymore since half of the excess costs of the high-risk pools are moved back into the underinsurance pools. What will happen to the enrollment rates for these underinsurance products when the premiums are jacked back up to unaffordable levels?

When people tell you that the McCain plan is almost as good as the Obama plan in reducing the number of uninsured, you now have a response. The McCain proposal provides nominal coverage with uninsurance plans for those who are healthy, but it doesn’t pay the bills for those who actually need health care.

Presidential debate – health care as a right

The Second Presidential Debate

October 7, 2008
Tom Brokaw: Is health care in America a privilege, a right, or a responsibility?
John McCain: I think it’s a responsibility…
Barack Obama: Well, I think it should be a right for every American…
http://elections.nytimes.com/2008/president/debates/transcripts/second-presidential-debate.html

Asking whether health care is a privilege or a right often leads to a not very productive ’tis so, ’tis not debate. But when the question is asked with the added choice of responsibility, and then answered, the answers can be very revealing.
If you believe that health care should be an individual responsibility, you might design reform based on a relatively unregulated market of private health plans.
If you believe that health care should be a right, you might design reform based on social solidarity with government guaranteeing that all of us receive the care that we need.
Proposals floated during political campaigns are rarely the final definitive proposals, especially with an issue as complex as our dysfunctional health care financing system. But it is important to understand the fundamental beliefs of those who we would elect to establish new policies addressing the problems that we face. A system that honors the right for everyone to obtain the health care that they need will look very different from a system that assigns the responsibility for obtaining health care to the individual.

Health Care Systems – Four Basic Models

An excerpt from correspondent T.R. Reid’s book on international health care, titled “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.” There are about 200 countries on our planet, and each country devises its own set of arrangements for meeting the three basic goals of a health care system: keeping people healthy, treating the sick, and protecting families against financial ruin from medical bills. But we don’t have to study 200 different systems to get a picture of how other countries manage health care. For all the local variations, health care systems tend to follow general patterns. There are four basic systems:

The Beveridge Model

Named after William Beveridge, the daring social reformer who designed Britain’s National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library. Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge. Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in 1997. Cuba represents the extreme application of the Beveridge approach; it is probably the world’s purest example of total government control.

The Bismarck Model

Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Despite its European heritage, this system of providing health care would look fairly familiar to Americans. It uses an insurance system — the insurers are called “sickness funds” — usually financed jointly by employers and employees through payroll deduction. Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model — Germany has about 240 different funds — tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides. The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.

The National Health Insurance Model

This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance. The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated. The classic NHI system is found in Canada, but some newly industrialized countries — Taiwan and South Korea, for example — have also adopted the NHI model.

The Out-of-Pocket Model

Only the developed, industrialized countries — perhaps 40 of the world’s 200 countries — have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die. In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease. In the poor world, patients can sometimes scratch together enough money to pay a doctor bill; otherwise, they pay in potatoes or goat’s milk or child care or whatever else they may have to give. If they have nothing, they don’t get medical care. These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we’re Britain or Cuba. For Americans over the age of 65 on Medicare, we’re Canada. For working Americans who get insurance on the job, we’re Germany. For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital. The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.

Note – Reid’s “Beveridge” model corresponds to what PNHP would call a single payer national health service (UK); “Bismark” model refers to countries that PNHP would say use non-profit “sickness funds” or a “social insurance model” (Germany); and “National health insurance” corresponds to single payer national health insurance (Canada, Taiwan). Reid’s “out-of-pocket” model is what PNHP would call “market driven” health care. Some countries have mixed models (e.g. Sweden has some features of a national health service such as hospitals run by county government; but other features of national health insurance such as physicians being paid on a FFS basis). This explains why Reid might classify the Scandinavian systems as “Beveridge” while PNHP classifies them as “single payer national health insurance.”

Presidential debate – health care as a right

The Second Presidential Debate

October 7, 2008

Tom Brokaw: Is health care in America a privilege, a right, or a responsibility?

John McCain: I think it’s a responsibility…

Barack Obama: Well, I think it should be a right for every American…

http://elections.nytimes.com/2008/president/debates/transcripts/second-presidential-debate.html

Comment:

By Don McCanne, MD

Asking whether health care is a privilege or a right often leads to a not very productive ’tis so, ’tis not debate. But when the question is asked with the added choice of responsibility, and then answered, the answers can be very revealing.

If you believe that health care should be an individual responsibility, you might design reform based on a relatively unregulated market of private health plans.

If you believe that health care should be a right, you might design reform based on social solidarity with government guaranteeing that all of us receive the care that we need.

Proposals floated during political campaigns are rarely the final definitive proposals, especially with an issue as complex as our dysfunctional health care financing system. But it is important to understand the fundamental beliefs of those who we would elect to establish new policies addressing the problems that we face. A system that honors the right for everyone to obtain the health care that they need will look very different from a system that assigns the responsibility for obtaining health care to the individual.

PBS Frontline Interview with T.R.Reid

Fall 2008

T.R. Reid is a veteran foreign correspondent for The Washington Post, a commentator for National Public Radio and the author of nine books, including three in Japanese. He is currently working on his 10th book, titled “We’re Number 37!,” in which he compares America’s health care system to others around the world. It is scheduled to be published by Penguin Press in early 2009.

How did you choose the five countries featured in this report?

Two of our choices, Britain and Japan, were pretty obvious. I had lived in both countries, I had doctors there and knew the systems. I could speak the language, sort of, in both places.

Beyond that, we were looking for examples of each of the established models of health care systems. The U.K. uses the Beveridge model; Taiwan has chosen the Canadian-style National Health Insurance [NHI] model; Germany, Japan and Switzerland use the Bismarck model. We went to three Bismarck countries on the theory that these private-sector systems are more relevant to America than a British-style National Health Service.

I got interested in Taiwan because Taiwan’s Health Ministry did what our film does; it traveled the world studying health care systems. In the end, Taiwan chose the Canadian model. We went to Switzerland because it is a ferociously free-market economy with politically powerful insurance and drug companies. But still, the Swiss managed to revamp their system, making it cheaper and fairer. We thought that might inspire Americans to believe that change is possible here, too.

You and your family lived in London and Tokyo; what was your experience with the health care systems there?

Our American family used the health care systems in Japan and Britain with considerable satisfaction. Fortunately, we never had a heart attack or cancer, but for the normal family medical problems — flu, measles, broken bones, earache, etc. — we got excellent care, with little or no waiting. During a trip to South Asia, I contracted a mysterious tropical disease that left me sick as a dog. When I got back to London, our family doctor diagnosed the problem precisely and found a fast cure.

In Japan, the prices were low; in Britain, there was no price at all. There was no bill! I loved that part of British health care.

In Japan my local government, Shibuya-ku — it’s a part of Tokyo — sent me a card every year on my birthday, urging me to get a comprehensive physical. I could go to any doctor or hospital in Shibuya, and the whole thing was free. When I did it, they checked everything — and I mean everything — that a man my age might have to worry about. This was a terrific example of preventive medicine.

In your upcoming book about health care you write about the five countries in this FRONTLINE report, as well as a few others. What are some of the good ideas America could learn from other countries?

As we say in the film, the World Health Organization studied every health care system on earth and rated the world’s richest country 37th in terms of quality and fairness. The top ranking in that survey went to France, so I went there to see what they are doing right.

The French private insurance system covers all 61 million residents of France, with excellent health results. There’s no “in-network” or “pre-authorization”; you can pick any doctor or hospital in France, and insurance has to pay the bill. Doctors are required to post their prices on the wall of the waiting room, so the mystery of American-style medical billing is removed.

Everyone in France has a green plastic card, the carte d’assurance maladie. That card has completely replaced paper billing and medical records. The result: administrative costs of 3 percent, compared to 25 percent in the U.S.

While France has achieved 100 percent digital record keeping, the U.S. is years behind on this technology. President Bush has made it a national goal to have 50 percent of American health records in digital form by the year 2014. Who would have thought that France would clean our clock when it comes to high-tech innovation?

The Austrians, who seem to do everything with a clockwork precision, have a precise, modern health care system that is a model of careful organization and cost control. But I think Austria may be too small and not diverse enough to be a model for the U.S.

Canada’s system is also pretty good. It has some notorious problems, including waiting lists, but I was impressed by Canada’s relentlessly egalitarian approach to health care.

Yes, Canada is one country in particular that many Americans think about when they think of health care. Can you talk a bit about their system: how it’s paid for, what works well, what needs fixing, and what we Americans get right and wrong when we talk about it.

Canada uses a National Health Insurance model; that means private providers but public financing. Everybody pays a premium to a single health insurer, run by the government. The Canadians call their system “Medicare,” and in fact our system of Medicare for the elderly is a good example of the Canadian-style National Health Insurance model.

Canada’s system started in a single province, Saskatchewan. The other provinces saw that it was working, and people demanded that it be expanded to the whole country. This suggests that if one American state set up a sort of Medicare-for-all system and it worked, then other states might demand the same kind of plan, and eventually we’d get a national system.

As we said in the film, the Taiwanese hired a professor at Harvard to study health care systems around the world and choose a model for Taiwan. In the end, they picked the Canadian model, on the grounds that it is cheaper and fairer than the for-profit insurance system used in the U.S.

Canada is fairly stingy in paying for health care; it spends about half of what we do, on a per capita basis. This leads to scrimping. That’s why Canadians often have to wait to see a specialist or have elective surgery. Some Canadians respond by crossing the border to buy treatment in the U.S. But most Canadians accept the delays, because they are roughly equal for everybody. A scholar there put it this way: “Canadians don’t mind waiting lines, as long as the rich Canadian and the poor Canadian have to wait about the same amount of time.”

There was another recent documentary about health care around the world: Michael Moore’s Sicko. Did you have that film in mind when you set out to make this report?

I thought Michael Moore did a good job in describing the shortcomings of the U.S. system. He didn’t pay much attention to our strengths: the best medical education in the world, the most innovative research, the best equipped hospitals. He is an advocate and had a point to make.

But Sicko was disappointing when Moore went overseas. He seemed to feel that all foreign health care systems are the same, that they are all “socialized” and that they all work great for low cost. I’d say that’s simplistic and wrong. We set out to take a more careful look at the different models in different countries. We saw their problems as well as their successes.

All five of these countries have achieved universal coverage for their citizens, but all five are grappling with rising costs as well. Is this simply a worldwide problem, or is there a fundamental difference between America’s rising health care costs and those in other countries? Which countries may be better able to keep a lid on them, and why?

Health care costs are rising everywhere, largely because health care is getting better. Doctors routinely save lives now that would have been lost a decade ago. A lot of this is due to new technology, and new technologies cost money. We shouldn’t complain about this. It’s hard to imagine anything more worth our money than good health and longer, happier lives. But this is the reason all the countries we visited are struggling with rising costs for health care.

In countries where there is a single health care system — and thus a single pool of money to pay for it — it is somewhat easier to control costs. Britain’s NHS often decides, for example, that it won’t pay for kidney dialysis for a 90-year-old. That means somebody’s grandmother will die, but at least Grandma and her relatives know that the money saved is going to be used to help some sick baby or some accident victim.

Limits like that are harder to impose in the U.S. because the money saved here doesn’t necessarily help another sick person. If Aetna or United Health declines to pay for somebody’s dialysis, the money saved is likely used for dividends to the stockholders or bonuses for the executives. That’s a little harder to swallow for the relatives of the sick patient.

It was interesting to learn in the report that some of Switzerland’s drug companies make one-third of their profits in the U.S. market. Are we subsidizing these other nations’ prescription drugs, and what would happen if America clamps down on prices?

Yes, we subsidize the whole world. Americans pay more for pills than people in any other country. Sometimes, the same tablet made in the same factory costs $1 in the U.S. and 20 cents in Britain. If we could negotiate lower prices in the U.S., the drug companies would then try to raise prices overseas to make up for the lost revenues.

The pharmaceutical industry spends billions on research. Drug companies say they would have to reduce R&D if Americans paid less for their drugs, but the companies spend more on marketing than they do on research. In Switzerland, when the government started negotiating lower prices for drugs, the companies cut their marketing budgets and maintained the level of R&D.

For the first time since 1992, health care is, according to a Kaiser Foundation poll, a top-three concern for voters, after the economy and Iraq. Do you think that reform is going to happen this time?

Yes. I am confident that we’re going to do it. I think Americans are ready for fundamental change, for two reasons.

First, our system is so expensive and inefficient that we can’t afford it anymore. It’s a big competitive disadvantage for U.S. industry. Second, Americans are too decent and too generous to accept a system that leaves tens of millions of our fellow citizens without access to health care. [According to the Institute of Medicine,] about 18,000 Americans die each year because they can’t get the medical treatment that would save their lives. That’s morally unacceptable.

So I think both the fiscal and the moral imperative will drive us to major change in 2009.

You note at the end of the report that none of the 2008 presidential candidates’ plans really encompass the ideas you found abroad. Do you think there’s a distinctly American approach that can solve the problems in our system?

To me, the candidates all seem to be tinkering at the margins of a system that needs fundamental change.

What we’ve learned overseas is that successful national systems have settled on one model — be it Beveridge, Bismarck or NHI — for everybody. This is fairer, cheaper and far more efficient than our badly fragmented crazy-quilt system.

I don’t think the systems we see in our film are un-American. The British system — the Beveridge model — is the same system used by the U.S. Veterans Administration. If this is un-American, why do we use it for America’s military heroes? And the Canadian system — the National Health Insurance model — is the model for Medicare. If it were un-American, would we use it for 36 million elderly Americans?

This is not the first project you’ve done that looked at how other nations address social issues differently — and often with better results — than the United States. Has this approach drawn criticism that you’re being too hard on America?

Anybody who dares say that other countries do anything better than America is liable to be called unpatriotic.

I wrote a book, Confucius Lives Next Door, pointing out that East Asian countries in the Confucian cultural sphere have much lower crime rates than the U.S., more stable families, almost no single mothers. And when I went on talk radio to promote this book, the hosts would say, “You hate America,” or, “Well, if Asia is so much better, why don’t you just move there?”

In fact, facing up to your country’s problems and trying to fix them is a sign of love for your country. The person who really cares about his college, his company or his country is the person who recognizes its shortcomings and tries to improve things. And one excellent way to do that is to study how other colleges, companies and countries have dealt with the same problem.

There are many cherished elements of American life that we copied from other countries: the Interstate Highway System (Germany), text messages (Finland), sushi (Japan), and American Idol (Britain). So it can’t be unpatriotic to suggest that we could cure our ailing health care system by borrowing ideas from overseas.

This report is about health care, but it’s also a travelogue of sorts. What was the most memorable moment from your travels in making this report?

I heard Big Ben toll the hours; I rode the bullet train past Mount Fuji; I ate leberwurst mit sauerkraut in Berlin; I flew a fighting kite on a beach in Taiwan; I strolled the breezy shore of Lac Léman with the president of Switzerland. All in all, a lovely trip.

For me, the best moment came at a new hospital in the fishing village of Jinshan, on the east coast of Taiwan. We went there with Professor Bill Hsiao of Harvard, the guy who designed Taiwan’s new health care system. In the hospital lobby, we met a woman, Mrs. Lee. She told me that her mother got breast cancer in the 1980s, when Taiwan had no [national] health care system and Jinshan had no hospital. Her mother died. In the late 1990s, the daughter, Mrs. Lee, also got breast cancer. By then, Jinshan had the new hospital and a health care system that gave Mrs. Lee treatment. She is now completely recovered.

I pointed out Professor Hsiao. I said, “Right over there is the guy who set up the health care system that treated your cancer.” So Mrs. Lee walked shyly over to Bill Hsiao; she gave him just a tiny, almost imperceptible bow. I thought it was a moving way for someone to say, “Thank you for saving my life.”

How Do You Think Your Healthcare is Trading?

By Donna Smith
Community Organizer
California Nurses Association

CHICAGO — If you think the companies that collect your health insurance premiums and pay your health care claims have been insulated from the economic crisis, think again. And if you think the health insurance industry that is suffering right alongside the financial services industry isn’t going to need a bail-out too, think yet again. Only the bail-out we will give the health insurance industry will be much more insidious and potentially far more dangerous to us all.

I wanted to inform myself about the stock performance of the big boys in the for-profit health insurance market, and here’s what I found this morning on Business Week’s website:

Stock performance, over the past month:

Aetna — down 25.03%

CIGNA — down 23.15 %

Humana — down 20.16%

Unitedhealth Group — down 27.95%

Wellpoint — down 20.59%

In fact, I couldn’t find one health insurance company traded on the stock exchange that looked very healthy right now. On its own, that’s not an indictment of the health insurance industry because so many businesses — if not most businesses — are losing money on Wall Street right now.

While the financial services industries were the first to the trough for bail-out, they won’t be the only private interests standing in line for some of our taxpayers’ funds. But when the private, for-profit health insurance industry comes calling, it will do so by raising premiums, denying claims and seeking to cover more Americans who won’t actually need to use many medical services. There are limited ways for the health insurance giants to recoup losses, and we are the way — our money, our ability to get the care we need and our lives depend on getting healthcare out of this folly.

We all know it. Healthcare isn’t like widgets or tires or hammers and nails. Healthcare is a human right. When we are sick, when our neighbor is sick, when our parent is sick, when our child is sick, and yes — even when our enemies are sick — we must have access to medical care. To see a doctor or other healthcare professional when we need it (and before it has become a crisis) is the way a humane and just society behaves.

But under the current, market sensitive and market driven pressures, healthcare morphs into a sort of odd blend of wealth-care for those who can still afford it as approved by for-profit insurance companies with enough resources to pay the claims. We can argue all we want to about the art of medicine, but when Unitedhealth Group drops nearly 30 percent in value in just one month, there isn’t any art to what they’ll be doing to the practice of medicine.

As a patient, I do not want my healthcare subject to the whims and the momentary fortunes of the stock market. I do not want to gamble on my healthcare or my children’s or my grandchildren’s. And I certainly don’t think the CEOs of those big corporations will want to take reductions in compensation or allow shareholders to suffer. Ronald Williams at Aetna, Edward Hanway at Cigna, Michael McCallister at Humana and Stephen Hemsley at Unitedhealth Group surely want to retain their millions in compensation even if that means denying me my prescription or my treatment or raising my premiums.

Any corporate losses resulting from the massive drops in value to the private health insurance industry in the current stock market environment will be absorbed by policy holders. You and me. Our employers. Our neighbors. Our families. Our health is in the hands of the stock market not those of our doctors and other healthcare professionals. And right now, my healthcare is worth a lot less than it was on Labor Day.

The only alternative to gambling with our healthcare in this volatile way is to make sure public funding backs up the healthcare system.

And I don’t know about other taxpayers — but I suspect many will feel as I do — I don’t want the funds I earn and the funds my taxes put in the public coffers to be used to pay for yet another corporate bail-out at my expense. I’ll gladly pay for my healthcare through a public fund but not their wealthcare. How does the saying go? Been there. Done that.

I do not want to pay monthly premiums and on top of those premiums to fund a bail-out to shore up health insurance company CEO compensation or shareholder dividends. And I cannot invest in the stock market by paying my health insurance premiums on time and wait for the market recovery in the estimated five to 10 years to recoup the investment. I might get sick and need actual healthcare.

I want the funds I contribute to healthcare to be used for healthcare. Period.

What reform does business want?

Business Cool Toward McCain’s Health Coverage Plan

By Kevin Sack
The New York Times
October 6, 2008
American business, typically a reliable Republican cheerleader, is decidedly lukewarm about Senator John McCain’s proposal to overhaul the health care system by revamping the tax treatment of health benefits, officials with leading trade groups say.
The officials, with organizations like the U.S. Chamber of Commerce, the Business Roundtable and the National Federation of Independent Business, predicted in recent interviews that the McCain plan, which eliminates the exclusion of health benefits from income taxes, would accelerate the erosion of employer-sponsored health insurance and do little to reduce the number of uninsured from 45 million.
Officials with eight business trade groups contacted by The New York Times predicted the McCain plan would raise costs and force some employers to stop providing health benefits.
A recent survey of 187 corporate executives by the American Benefits Council and Miller & Chevalier, a consulting firm, found that three-fourths felt the repeal of the tax exclusion would have a “strong negative impact” on their workers. Only 4 percent said they would provide additional pay to fill any gaps.
http://www.nytimes.com/2008/10/07/us/politics/07health.html?pagewanted=all

Where does American business really stand on health care reform?
Employers remain very concerned about rising health care costs. Because of our failure to reform our health care financing system, employers have been responding by shifting more responsibility to their employees. There has been an increase in the use of high-deductible health plans, which slow the rate of premium increases for the employer, but makes health care less affordable for the employees by requiring greater out-of-pocket payments when health care is accessed. Many employers now have decided not to offer health plans; the rate of coverage through employer-sponsored plans has continued to decline, especially amongst small businesses.
The McCain proposal is designed to relieve employers of the responsibility of providing employer-sponsored plans, both by eliminating the tax benefit for the employees and by offering individuals tax credits for purchasing plans in the individual market. It is not only the Obama camp that recognizes the erosion of health coverage that this would cause, the business community recognizes it as well. Most American businessmen are concerned about the welfare of their employees. They really don’t want a solution that would have a “strong negative impact” on their employees.
So would business be more supportive of the Obama proposal? The most important component of his proposal is to offer a market of quality plans similar to those used by federal employees. But isn’t that what they have now? Isn’t that precisely why the business community is seeking relief? Even Barack Obama understands that these plans are too expensive, and many would still have to go without coverage.
The American business leadership certainly understands the single payer model. One of the most important principles for a successful business is to reduce waste, and that is precisely what the single payer model does, by design. Adopting a single payer system would allow us to cover everyone, and would allow us to finance it equitably through a single universal risk pool.
When we desperately need sound business principles to drive health care financing, it really seems silly to digress into a not-very-intellectual debate over free markets and the government, as if they were two distinct entities between which a choice had to be made. Nebulous debates lead to nebulous results (and is probably the reason why conservatives keep drawing us into that debate).
Some leaders in the business community must be ready to support sound business principles in revamping our highly flawed health care financing system. An intellectual debate over ideology might make for an interesting pastime, but first we have to get our dollars in order. Every businessman understands that.