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Market justice and moral compass

Archives for 2008

Market justice and moral compass

Market Justice and US Health Care

By Peter P. Budetti, MD, JD
JAMA
January 2, 2008

In the United States, health care competes for consumers with other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, self-interest, personal effort, and voluntary behavior. The contrasting approach, social justice, allocates goods and services according to the individual’s needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity. Social justice in health care requires universal coverage and ensured access to care, whether through social insurance, private insurance, or some combination.

The End of Market Justice

The dominance of market justice as the vehicle for allocating health resources in the United States has been associated with numerous troubling characteristics of its health system. The US population has clearly rejected using pure market justice to apportion health care goods and services, yet has expressed no collective demand that society achieve equity through social justice. The general public has insisted on the buffer of insurance, but has focused on coverage for individuals and their respective families, not the population as a whole. Consequently, health care coverage, although desired by the vast majority of Americans, is incomplete. Now, the key element, employment-based insurance, is disintegrating in both the population that is covered and the benefits provided.

Simultaneously, health care has become a valuable commodity that created enormously influential vested commercial interests with little motive to abandon market justice. Medicine, which might have played a role in promoting social justice, has not done so, and has been transformed by the imperatives of market justice. Fragmented and struggling to come to terms with externally imposed pressures, medicine is losing both its political force and moral compass. The medicalization of health has simultaneously enhanced the investment in health care goods and services while distracting clinicians and policy makers from attention to the needs for health promotion and disease prevention and constraining the capacity to meet the expanding challenges to public health. Market justice may have outlived its role in US health care.

http://jama.ama-assn.org/cgi/content/full/299/1/92

Comment:

By Don McCanne, MD

The quasi-electromagnetic fields of market justice have screwed up our moral compass. Let’s take it over to the terrain of social justice and see if we can get it to work again.

Denying care or denying payment?

Take a deep breath, and read

By Steve Lopez
Los Angeles Times
January 2, 2008

Preston doesn’t have cancer, but he was born with cystic fibrosis. And the cost of the medicine that keeps him breathing just shot up like a rocket, thanks to an insurance company decision I’m still trying to decipher.

… the cost of Pulmozyme… had been running them $30 a month. Suddenly it was $784.

If a cheaper generic were available, they’d gladly switch. But they said there is no substitute for Pulmozyme, an enzyme-based medication that controls mucus secretions.

Hoping for an explanation, and reconsideration, Preston’s parents filed a grievance. Blue Cross quickly rejected it.

“Pulmozyme is no longer a Formulary medication,” said the virtually incomprehensible letter, which gallingly suggested the increase was part of Blue Cross’ commitment to providing its customers “the best possible care and access to medications.”

When I asked Blue Cross for an explanation, I got this by e-mail:

“As with other health plans, the decision to add or remove a drug from the formulary is done through a review committee made up of medical experts. At Blue Cross, this group is the Pharmacy and Therapeutic committee. Pulmozyme is currently considered a specialty medication and is covered for our members, but at a higher member share of the cost than other medications. The goal of these ongoing reviews is to assure access to all necessary drugs while also keeping costs as affordable as possible for all of our members.”

http://www.latimes.com/news/local/la-me-lopez2jan02,1,3588546,full.column?coll=la-headlines-california

And…

Individual and Family Health Care Plans for California

Blue Cross of California

We believe that the cost of our plans should be consistent with a member’s expected health care needs and risk factors. That’s why Blue Cross offers various levels of coverage.

http://www.bluecrossca.com/member/noapplication/plansbenefits/individualsfamilies/medicalplansummaries/pw_a082352.pdf

And…

Moves from the Cigna playbook

By Giuseppe Del Priore
Los Angeles Times
January 3, 2008

Insurers always qualify their denial letters with a sentence to the effect that the doctors must provide whatever care is necessary and that the payment is a separate issue. Insurers never deny care — only the authorization for payment. To stall the actual delivery of care, insurers hold out an insincere promise to authorize payment if the doctor provides more information. This leads the doctor on indefinitely, while insurers never say absolutely “no” until the patient gives up or dies.

http://www.latimes.com/news/opinion/web/la-oew-delpriore3jan03,1,7350723.story

Comment:

By Don McCanne, MD

Preston’s family pays $1,200 per month for their high-deductible health plan. You would think that this premium would provide a level of coverage that Blue Cross states is “consistent with a member’s expected health care needs and risk factors.”

Blue Cross has been a leader in insurance plan innovations that slow the rate of premium increases (to a smaller multiple of the rate of inflation) in order to remain competitive in the health insurance market. Blue Cross suggests that they are balancing “assuring access” with “keeping costs as affordable as possible for all of our members.” But their scales are locked in at (barely) affordable premiums, which requires that they increase financial barriers to access. Changing the copayment for Pulmozyme from $30 to $784 is a good example. They continue to have “access” since Pulmozyme is still covered in another drug tier, and they continue to have “affordable” insurance premiums.

Giuseppe Del Priore’s op-ed makes a very important point. Insurers never deny health care. They only deny payment. They have a private contract with the patient, and they have another private contract with the health care provider. They do not use those contracts to prevent health care from being accessed; they use them to escape their obligation to pay for that care.

Or do they actually have that obligation? Not really. Their obligation is to succeed as a business entity by enforcing those contracts in a manner that accrues to their own financial benefit. That’s the way the marketplace works.

What if we had a universal public insurance program, owned and financed by the taxpayers? Would we have individual contracts with patients and providers that would be used to manipulate health care payments to accrue to the benefit of the administrators of the public program? Of course not.

Would we use our public program to deny access to health care? We might if that care were demonstrated to result in impaired health outcomes and impaired quality compared to care complying with more appropriate standards. But we would do that through a process that identifies beneficial practices and then realigns incentives.

Instead of a private system that uses innovations to deny payment for appropriate care, wouldn’t it be better to have a public system that is specifically designed to finance all reasonable health care services and products? Blue Cross doesn’t think so.

Editorial: Honesty in health care

By Bangor Daily News Staff
Monday, December 31, 2007

Polls show that health care is a major issue — rivaled only by the Iraq war — in the current presidential campaign. Complaints about the present system include the mounting cost, the many left out, poor service and too much paperwork. Yet all the major candidates of both parties advocate only makeshift modifications of a system widely viewed as broken.

Republican candidates insist on keeping health care “market based,” which sounds great but has left some 47 million Americans uninsured and produces exorbitant salaries, huge advertising campaigns and enormous political contributions from the insurance and drug industries. They stoke the widespread fear of “socialized medicine” fostered by generations of propaganda.

Most Democratic candidates do the same, though without saying so, and stick to the accidental and failing linkage of health care and employment. That connection began in World War II, when employers dodged wage caps by offering health benefits instead of pay raises, and has hung on ever since. Now large as well as small businesses are finding health benefits an unsupportable burden. Only Dennis Kucinich, Mike Gravel and Bill Richardson dare to favor an active role by the federal government, and they probably have no chance of getting the nomination.

So whoever the nominees are, the presidential race looks certain to avoid any consideration of a fundamental change in the present American health care system, which costs twice per capita what is paid by virtually all other developed nations, while the United States rates 37th in overall performance according to the World Health Organization and has the highest infant mortality rate and highest prescription drug costs in the industrialized world.

Two Harvard professors, co-founders of Physicians for a National Health Program, advocated a “single payer” health plan for the United States, in the Dec. 15 New York Times. David U. Himmelstein and Steffi Woolhandler wrote that the various efforts to reduce the number of uninsured were all little different from a 1971 plan by President Nixon and did little or nothing to reduce the number of uninsured. They write that only a single payer plan could cut costs substantially and estimated the savings at $350 billion.

But the major candidates seem put off by faulty arguments such as that the Canadian plan is disliked by some doctors and involves long wait times for elective surgery. Yet polls show that most Canadians prefer their plan to ours. And wait times, which don’t interfere with emergency medicine, could be rectified by better financing.

Much of American health care is already run quite satisfactorily on a single payer basis: Medicare, Medicaid and the veterans’ health system.

Government run health plans, usually single payer plans, are good enough for Canada, Britain, France, Denmark, Sweden, Germany, Australia, New Zealand and most other developed countries. Why can’t they even be considered and debated by candidates for the U.S. presidency?

If both parties continue to avoid even mentioning a single payer plan, election day could see ballots marked “none of the above.”

Cancer is hitting uninsured harder

Associated Press
The Boston Globe
December 20, 2007

ATLANTA – Uninsured cancer patients are nearly twice as likely to die within five years as those with private coverage, according to the first national study of its kind and one that sheds light on troubling healthcare obstacles.

People without health insurance are less likely to get recommended cancer screening tests, the study also found, confirming earlier research. And when these patients finally do get diagnosed, their cancer is likely to have spread.

The research by scientists with the American Cancer Society offers important context for the national discussion about healthcare, analysts said.

The new research is being published in Cancer, the cancer society’s medical journal. In an accompanying editorial, the society’s president repeated the organization’s call for action to fix holes in the healthcare safety net.

“The truth is that our national reluctance to face these facts is condemning thousands of people to die from cancer each year,” Dr. Elmer Huerta wrote.

Hard numbers linking insurance status and cancer deaths are scarce, in part because death certificates don’t say whether those who died were insured.

An Associated Press estimate – based on hospital cancer deaths in 2005 gathered by the US Agency for Healthcare Research and Quality information and other data – suggests that at least 20,000 of the nation’s 560,000 annual cancer deaths are uninsured when they die.

That’s about 4 percent of the total cancer death toll. One reason is that most fatal cancers occur in people 65 or older – an age group covered by the federal Medicare program.

Some are enrolled in Medicaid or other programs after diagnosis, when the condition worsens and their finances erode. But such 11th-hour coverage can be too late; early detection is the key to catching many cancers before they’ve grown beyond control, analysts said.

(c) Copyright 2007 Globe Newspaper Company

Medicare For All via H.R. 676

Stephen Crockett

It is obvious that none of the major Presidential candidates of either the Democratic or Republican Parties are supporting the right approach to providing universal healthcare. Frankly, all the Republican candidates are going to be major obstacles to achieving this national goal. While the top Democratic candidates (Clinton, Edwards and Obama) do support the concept, they are all offering Band-Aid approaches for a life-threatening economic and health crisis in America.

A bill has already been introduced in The House by Congressman John Conyers that effectively addresses the issue. H.R. 676 expands Medicare to cover all citizens.

The scope of the healthcare crisis in America is huge. It has very serious economic and moral implications. It is crippling our nation in terms of protecting American manufacturing, competing in the global economy and undermines our national security. It reflects badly on us as a just and moral society. It is literally killing Americans in huge numbers.

The number of Americans without health insurance is currently 47 million and growing rapidly. The number of underinsured Americans is much larger than the number of uninsured Americans. In America, over half of all personal bankruptcies are the direct result of medical crises. Over half of those bankruptcies are from individuals who had health insurance when their medical crises started.

Industry friendly studies of the number of Americans who died because they had no health insurance place the number at around 50 per week. The number is absurdly low and illogical.

Doing without healthcare at any point in life for a significant period of time will likely create health issues and physical damage. This damage accumulates over a lifetime and shortens your lifespan. You die younger than you would have if you had always had adequate healthcare. You might die at 70 instead of 85. In addition, the last years might have much lower levels of quality. Since most people die after reaching the age where Medicare coverage is already in effect, those deaths are not counted as resulting from a lack of healthcare insurance although they can be directly traced to an earlier lack of coverage. Most of the deaths resulting from a lack of healthcare insurance are thus concealed.

Even using the fraudulent 50 per week figure, killing Americans to preserve the profits of HMO’s and insurance companies is completely immoral. Bankrupting Americans because of illness is a national disgrace. It does not happen in other industrialized nations. Out of the top 75 most industrialized nations in the world, only in the United States are citizens not provided by their government with universal healthcare.

In the United States, we saddle our businesses and corporations with the cost of providing for the healthcare needs of their employees. Our international competitors do not. This is one of the major reasons why good paying manufacturing and service sector jobs are leaving our nation. It is economic suicide.

None of the Band-Aid approaches advocated by the top Democratic Presidential candidates deal effectively with the trade implications of healthcare policy. I am personally supporting Edwards because he is more inclined to advance fair and balanced trade agreements than Clinton and Obama. For example, Clinton and Obama supported the most recent “so-called free trade” agreement with Peru while Edwards did not. However, even Edwards has not yet addressed the clear connection between international trade and healthcare.

The best solution for providing universal healthcare is expanding Medicare to cover all American citizens. Medicare is a proven program. It is popular and cost-effective. Our current private system has much higher levels of overhead costs than does Medicare. The only inefficient aspects of Medicare are the “privatized” programs added by the Bush White House and their Republican allies in the Senate. Medicare has been hugely successful despite ongoing Republican and corporate attempts to undermine it.

We can count on Republican politicians to label any move toward universal healthcare as “socialized medicine.” They attempted mightily to destroy Medicare in the past using such tactics and failed completely. Politically, providing universal healthcare by expanding Medicare will be much easier than any other approach.

The private, profit-drive healthcare system is terribly unfair and inefficient. We spend 17 percent of our total economy on healthcare while our international competitors spend only 8 percent. They cover everyone and we do not. The numbers speak for themselves!

Expanding Medicare to cover everyone will not prevent citizens from buying supplemental healthcare if they can afford it. It will greatly help doctors who are General Practitioners by making medical need become effective demand. It will help hospitals by removing the burden of providing healthcare to those who cannot pay for it. It will make our workers healthier and more productive.

There must be a grassroots movement built behind “Medicare For All.” Local activists, union leaders, businesses and politicians must all exert their efforts in a common movement. Most national union organizations and state AFL-CIO organizations are supporting H.R. 676. They are joined by many members of Congress. The legislation has 89 co-sponsors with more being added frequently. Many candidates are backing it!

Local leaders are already getting organized all over the nation. People like Amos B. McCluney, Jr. in Delaware and Alena Bandy in Maryland are actively organizing Medicare For All state chapters. Both leaders are grassroots Democratic activists with roots in the United Auto Workers. Both are reaching out into the community recruiting civil rights leaders, churches, community organizations and local politicians behind H.R. 676. They are not alone. I personally have talked with local activists from Tennessee, Massachusetts, New York, Pennsylvania and several other states who are working on building support for this legislation.

Pressure must be placed on all opinion leaders to support Medicare For All. Presidential, Senatorial and Congressional candidates should be pressured to support H.R. 676. All candidates should be placed on record that they would not veto Medicare For All nor place legislative obstacles in the way of passing H.R. 676, even if they do not actively support passage. Candidates failing to make such public pledges should not be supported by any American citizen.

Average Americans must reframe the debate over healthcare. Instead of calling for universal healthcare or single-payer healthcare, we should simplify the debate. We should be calling for “Medicare For All” and supporting H.R. 676.

Written by Stephen Crockett (co-host of Democratic Talk Radio http://www.DemocraticTalkRadio.com and Editor of Mid-Atlantic Labor.com http://www.midatlanticlabor.com ). Mail: P.O. Box 283, Earleville, Maryland 21919. Email: midsouthcm@aol.com . Phone: 443-907-2367.

Feel free to publish without prior approval

CIGNA Capitulates to Patient Revolt

Following Massive Protest, Insurer Authorizes

Transplant for 17-year-old Nataline Sarkisyan

CNA/NNOC-Sponsored Protest Sparks Flood of Calls from Across U.S.

In a stunning turn around, insurance giant CIGNA has capitulated to community demands, and protests that the California Nurses Association/National Nurses Organizing Committee helped to generate, and agreed to a critically needed liver transplant for Nataline Sarkisyan, a 17-year-old girl in the intensive care unit at UCLA Medical Center.

A national web of friends and family of Nataline, CNA/NNOC registered nurses, doctors, members of the Armenian community, healthcare advocates, and netroots supporters pitched in on an unprecedented national day of action on Nataline’s behalf.

The centerpiece of the protests was an impassioned rally today sponsored by CNA/NNOC with the substantial help of the local Armenian community that drew 150 people to the Glendale offices of CIGNA. Hundreds of phone callers clogged the lines of CIGNA offices around the country, all demanding that CIGNA reverse its prior denial of care.

“This is an incredible turnaround generated by a massive outpouring around the country that proves that an enraged public can make a difference and achieve results,” said CNA/NNOC Executive Director Rose Ann DeMoro. “CIGNA had to back down in the face of a mobilized network of patient advocates and healthcare activists who would not take no for an answer.”

The netroot protest was organized by Eve Gittelson, an influential health policy blogger who writes on Daily Kos as nyceve, and many of the calls were also the product of work by the Armenian National Committee.

“Nataline is now seriously ill and still has significant hurdles in her fight for her life, but thankfully our combined voices and protests have finally given her and her family hope,” said Geri Jenkins, RN, a member of the CNA/NNOC Council of Presidents who works in a transplant unit at the University of California San Diego Medical Center.

“However, it is deplorable and appalling that CIGNA needed to have hundreds of people pounding on their doors and besieging them with calls to take the humanitarian step they should have done long before today,” said Jenkins, who spoke at the Glendale rally.

Nataline’s mother, Hilda Sarkisyan, expressed her profound thanks to CNA/NNOC. “We couldn’t have done this without you helping us to stand up against this insurance company and forcing them to finally do the right thing. It is not right in this country for it to take a rally, a protest, and a major press conference to get an insurance company to listen.”

“Every politician who thinks the answer to our healthcare crisis is more insurance should stop and think about Nataline Sarkisyan,” said DeMoro. “Insurance is not care. Paying for insurance coverage is not the same as assuring you will receive appropriate care, even when recommended by a physician as it was for Nataline. Insurance corporations profit by denying care to the sick, and that is no way to run a humane healthcare system.”

DeMoro said that CNA/NNOC will continue to encourage patient protests and publicize stories about insurance companies’ denial of care, as it has all year through its www.guaranteedhealthcare.org website, while pressing for real healthcare reform “that takes medical decisions out of the hands of insurers and places them where they belong, in the hands of healthcare professionals and their families.”

Background on case:

“My daughter survived two bouts of cancer, and against all odds has been stable even with so many of her organs not working, only to be told that she cannot get the only treatment that will save her life because some administrator in some office thinks it is too expensive,” said Hilda Sarkisyan. “We needed help in standing up against this insurance provider, and of course it was the nurses who stepped forward.”

In a Dec. 11 letter to CIGNA’s transplant department, four UCLA physicians said that Nataline “currently meets criteria to be listed as Status 1A” for a transplant and urged the company to “urgently re-review her case” and their denial. CIGNA said it denied the care because their benefit plan “does not cover experimental, investigational and unproven services,” to which the doctors replied, “Nataline’s case is in fact none of the above.”

On Dec. 14, Hilda Sarkisyan was told by the hospital that a healthy liver was available, but because CIGNA had refused authorization, the family would have had to make an immediate down payment of $75,000 to proceed, an amount the family could not afford.

CNA/NNOC is the nation’s largest and fastest-growing union of direct-care RNs, with some 75,000 members in all 50 states.

Evaluation of Colorado Blue Ribbon Commission for Health Care Reform Final Recommendations

by Michele Swenson
Board Member, Health Care for All Colorado
Co-Authors of Colorado Health Services Single Payer Proposal
January 2, 2008

Overview: Colorado Blue Ribbon Commission for Health Care Reform

(Draft) Final Report / Recommendations to the Colorado General Assembly (Due Date: 1-31-08)

During its 15-month length of service, the Colorado Blue Ribbon Commission for Health Care Reform — comprised of 27 members statewide appointed by two governors and 4 legislators — will have received 31 proposals (23 comprehensive, 7 Single Payer). Five proposals were selected to be evaluated by the Lewin Group, including an additional proposal written by a subcommittee of the Commission. The Colorado Health Services Single Payer Proposal is the only reform proposal that demonstrated any savings for the state — $1.4 billion — and also the only one capable of providing comprehensive health care for all. The Colorado Commission chose to base most of its recommendations on its own (5th) Proposal.

The 208 Commission Recommendations fail to address:

* Rising cost of health insurance premiums (82% increase in 6 years in Colorado), as well as copays, deductibles and prescriptions

* The U.S. fragmented commercial health insurance system that siphons more than 20 percent of health care dollars to profits, exorbitant CEO salaries, etc. and duplicative layers of administrative waste.

* A greater than doubling of median family income spent on health insurance: 7.7% in 1987 to 19% in 2005

* As premium costs continue to increase, coverage has decreased: “Insurance does not equal health care.”

The 208 Commission’s proposed solution:

* A cornerstone of the Commission Recommendation is the Massachusetts-style ‘Individual Mandate’ to purchase private insurance, with a substantial tax penalty for failure to comply.

* The Commission counts heavily on taxpayer subsidies to private insurances.

* The Commission asserts that all cost-shifts are due to the uninsured – yet Lewin’s Graph on Cost Shift shows that the uninsured and underinsured combined (labeled ‘self-pay’) contribute less than 20% to the total cost-shift burden. John Sheils of the Lewin Group informed the Commission that half of all uninsured payer their own health care bills.

* The Commission Recommendation states: “A minimum benefit plan – a leaner health insurance package with high deductibles, annual caps or limited benefits (average monthly premium $200/individual) is considered essential for assuring availability of an affordable product.”

Shortcomings of 208 Commission Recommendations:

* The Massachusetts-style ‘Individual Mandate’ creates a captive market for commercial insurance without attaching either quality or cost controls to insurance charges. In Massachusetts, 2008 marks the 8th year of average double-digit premium increases, resulting in more who cannot afford insurance and are moved into subsidized or public insurance at taxpayer expense. (Boston Globe, 9/13/07, 12/5/07)

* The 208 Commissioin seeks to solve one problem by exacerbating another — by moving more of the uninsured into underinsurance, or Minimum Benefit Plans. Attributing all unpaid medical bills to the uninsured and to under-reimbursed public programs, the Commission disregards the rising trend of unpaid medical bills by the underinsured. The annual TrendWatch Reports of the American Hospital Association reveal that out-of-pocket costs have risen from $146.3 billion in 1995 to $249.4 billion in 2005 – a 59% increase that parallels the 60% increase in unpaid medical bills over the same period. See Graph of Increasing Out-of-Pocket Expenses.

* The Families USA Report Too Great a Burden: Colorado’s Families At Risk (12-13-07) reveals that 1,054,000 people under the age of 65 in Colorado are in families that will spend more than 10% of their family income on health care costs in 2008 before accounting for taxes. Out of these people, the vast majority, 82.6%, have insurance. Out of these Coloradans, 299,000 live in families that will spend more than 25% of their pre-tax income on health care costs in 2008. The numbers of underinsured people have increased since previous studies in 2000, and as a result, put thousands of families at risk due to a growing health care burden. Families USA: Colorado’s Families At Risk

* As premium rates continue to rise faster than the rate of inflation or wage increases, more employers will either drop health coverage or move employees into Catastrophic ‘Minimum Benefit Plans’ with high out-of-pocket costs that leave families vulnerable to increasing health and financial risk, and also contribute to over 50% of personal bankruptcies precipitated by high medical bills.

* The Commission Recommendations add many new categories of coverage, eligibility testing, and new departments of administration, as well as taxpayer subsidization, multiplying administrative and public costs of health care.

Some goals defined by the Commission — “to provide consumers with “a choice of insurances” and to “ensure the ongoing viability of Colorado’s insurance markets” — falsely equate insurance with health care access. People want a true choice of health care, not choice of ‘minimum benefit’ insurances. The Commission Report begs the question: Is reform intended to insure the bottom line of the health insurance industry, or health care access for all?

It is telling what the Commission left out of the final report — Statements from the Vulnerable Populations Task Force Report to the Blue Ribbon Commission, September 28, 2007:

* “Mandating the purchase of a minimum benfits package forces residents to pay for underinsurance and is in direct conflict with the guiding principles of the Commission. We must not exchange our uninsured for masses of underinsured.”

* “The Lewin analysis established that current expenditures in health care would finance comprehensive health insurance for all Colorado residents under the Colorado Health Services proposal with $1.4 billion in savings to the state of Colorado. We should not consider healthcare to be a commodity, as we do not choose to get sick. The Vulnerable Populations Task Force asks the legislature to have the vision to do what is best for all the residents of Colorado. If this is not possible, we offer our recommendations on elements of health reform that could benefit Vulnerable Populations.”

Single Payer merited just 4 sentences in the Commission’s final report. Single Payer: “…viewed by the Commission as being too disruptive of current coverage and also unworkable in a single state.”

Nevertheless, the Single Payer model is uniquely capable of overcoming many problems that the current system and other proposals cannot. No other proposal would create a single Health Trust Fund combining administration of all health care monies, insulated from the politics of the State General Budget (and such constraints as TABOR and Averschoug-Bird, etc.).

Single Payer transparency and accountability of data overcomes the problem of secret proprietary data of numerous private insurance companies, and permits evaluation of best practices and outcomes in a statewide Health Information Technology system. While all other proposals call for substantial increases of state Medicaid spending (funds constrained by General Budget rules that simultaneously limit spending in other areas), Single Payer alone can create a true cost-effective single-risk pool insurance by consolidating multiple categories of medical care that now fall under such categories as Auto, Workers’ Comp and Medicaid/Medicare, to eliminate administrative waste. Single payer can overcome the federal limits on provider reimbursements that hamper Medicaid/ Medicare. Only Single Payer provides true choice of providers a
nd hospitals. Currently, employees’ choice of providers is limited within an employer’s health plan; change of plans requires change of providers, disrupting health care. Improved Coverage & Cost Savings of Colorado Health Services Single Payer Proposal

The Commission’s Reform Proposal sets the stage for a continued downward spiral: As premiums increase and benefits decrease, more people can no longer afford insurance and more are moved into public programs at taxpayer expense.

Free drug samples go to wealthy, insured

By Kim Dixon
Reuters
January 2, 2008

WASHINGTON (Reuters) – Insured and wealthy Americans were more likely than the poor to get billions of dollars in free drug samples distributed by pharmaceutical companies to win patient and doctor loyalty, a study released on Wednesday showed.

The pharmaceutical industry contends that the samples help the uninsured and people with low incomes, but the study of prescription use by nearly 33,000 U.S. residents during 2003 found that the neediest were least likely to get samples.

“Our findings suggest the free samples serve as a marketing tool, not a safety net,” said Dr. Sarah Cutrona, co-author of the report to be published in the February issue of the American Journal of Public Health.

The Pharmaceutical Research and Manufacturers of America, a trade group representing most major drugmakers, called the study out of date and said a major facet of the problem is that many uninsured do not get healthcare from doctors’ offices.

Samples are popular among doctors who want to try new drugs.

“As important as free pharmaceutical samples are in improving healthcare, they represent one – not the only – option for patients in need,” Ken Johnson, a spokesman for the group, said in a statement.

Lack of access to regular medical care by the uninsured and underinsured is a major factor contributing to who gets free drug samples, the report said. The uninsured are more likely to get care from emergency rooms and clinics.

Nearly 47 million people living in the United States do not have health insurance.

NEW, EXPENSIVE DRUGS PROMOTED

About $16.4 billion in drug samples were given out in the United States in 2004, up from $4.9 billion in 1996, the study said. Distributed by sales representatives, samples are nearly always the newest, most expensive drugs, the report said.

Critics have said that in addition to steering doctors and patients to pricey drugs, samples can lead to medications being used for conditions they were not intended to treat.

Drugmakers are forbidden from recommending drugs for uses for which they have not been approved by the U.S. Food and Drug Administration, but doctors can prescribe drugs for any use.

The now-recalled painkiller Vioxx, made by Merck & Co, was the most frequently distributed free drug sample in 2002, the study found.

Vioxx was often prescribed beyond its approved uses before it was withdrawn from the marketplace because of a link to an increased rate of heart attacks and death.

The study analyzed U.S. government data in a 2003 nationally representative survey, and found that about 12 percent of Americans had received at least one free sample.

About 13 percent of those with insurance were given a sample, while about 10 percent of those who were uninsured for all or part of the year got one.

Seventy-two percent of those who received a sample had income in excess of 200 percent above poverty level, while 28 percent had income below poverty level.

William Shrank, a physician at Boston’s Brigham and Women’s Hospital who studies pharmaceutical use in large populations, said the study “helps debunk the assertion” that drug samples help the needy.

Brigham and Women’s Hospital bans sales representatives, but Shrank described how early in his career he worked at academic centers where representatives freely roamed the halls. For doctors short of time and unable to keep up with medical literature, “You are getting biased data. It’s not objective,” Shrank said.

(Editing by Braden Reddall, Leslie Gevirtz, Toni Reinhold)

Where are we on reform? Part 2 (Hacker)

Health Reform Lessons from the Past

Jacob Hacker, PhD
National Conference on the Un and Underinsured
December 12, 2007 (Day 3)

Now I have one big point… and it is that although we are all for the most part health policy wonks, we read Health Affairs, we love to talk about the billions that will be saved doing this and the fine-tuning of mandates and the like, the bottom line is that health care reform is about politics. If real estate is about location, location, location, health care reform is about politics, politics, and politics.

So when the rhetoric heats up reformers are going to have to fight fear with fear. The fear of losing coverage against the fear of government, the fear of medical bankruptcy and debt against the fear of taxes, but they’re also going to have to be able to fight fear with hope. With a clear, simple and unthreatening vision that builds on what exists and meets public concerns head on, a vision that may lack the intellectual satisfaction of a fine-tuned policy blueprint, but which provides the political satisfaction of actually having a chance of passage. Now I think there’s some evidence the reformers have taken this message to heart, though simplicity and clarity still remain pretty elusive in the discussion.

…as we learned this morning, all the top tier Democratic candidates… would include some kind of shared financing requirement with employers either being required to pay or play, and these proposals would all, either eventually or immediately, have some kind of mandate.

Now I think this approach lacks much in terms of conceptual and policy clarity or the inspiration that David Himmelstein provided us earlier today about the sort of large scale reforms we need, but it does have some pretty big political virtues. And I should say I guess in the interests of full disclosure that I’ve been peddling an idea largely along these lines for the last few years. For one thing it means that the vast majority of people who now have private health insurance coverage through their employer would continue to have it.

This time the fight is going to take place on the scorched earth of partisan warfare and that means that we’re going to have to adopt strategies that reflect new political realities. In my view that means a much stronger clarity about ends but much greater willingness to compromise on means, a much greater attention to coalition building from the very beginning, well before a sympathetic President enters office…

http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2283

Transcript (Jacob Hacker’s comments begin on page 39):
http://www.kaisernetwork.org/health_cast/uploaded_files/121207-underinsured%20part%202.pdf

Comment:

By Don McCanne, MD

The final Quote of the Day for 2007 discussed the disconnect between a new poll indicating strong support (65%) for “a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers,” and a rapidly growing movement within the progressive community to support a model based on allowing you to keep the insurance you have.

Although the policies discussed in that message were on target, the tone was quite negative and detracted from the important thrust of the policies behind the message. The message included inappropriate cynical misdirections of my obvious anger. I decided that in the first message of 2008 I should clarify and expand on the important message in my last qotd, but in a less pejorative manner.

Jacob Hacker has described very accurately the politics of health care reform. He has suggested an approach that, on surface, would appear to lead to affordable coverage for everyone, while passing the crucial test of political feasibility. His political message is very sound – in fact, so sound that the leading Democratic candidates have adopted his suggestions. He has stressed the importance of coalition building well in advance of the installation of a new government one year from now.

So what coalition activities are we seeing within the progressive community? Many respected, influential leaders state that it is time to set aside the policy debate and proceed with a political strategy that will achieve our reform goals. There is one major problem with this approach: most of the difficult policy issues have yet to be addressed. But several of these coalition leaders have told the policy community quite bluntly that the policy debate is over, and all of the activities now must be about unity. We are commanded to unify behind health care reform that promises that you can keep the insurance you have or have the option to buy into a public program.

That’s it. That’s the policy behind which we are to unify. For the sake of unity, we are not to talk about the inability of the private insurance industry to provide us with affordable health plans that are comprehensive enough to meet our health care needs. We are not to talk about a public insurance program that must provide a premium that is competitive with private plans insuring the healthy, when the public plan is weighted down with high-cost patients (adverse selection).

Even though the policy debate is swept under the table, let’s suppose that the political strategy is effective. When we have a Congress and a president who support an individual mandate with a public option, what process will be used to resolve the policy issues? How will they require the private insurance industry to provide reasonably comprehensive plans that are still affordable? How will they create an optional public program with a concentration of the most expensive patients without a massive taxpayer subsidy? What will the voter response be to a program costing far more in taxes than any of the candidates would acknowledge during the campaign?

The policy issues do matter. The politically motivated promise of an affordable individual mandate and an affordable public option cannot be met. Fundamental structural reform is essential. Unless the politicians are able to engage successfully in bait and switch strategies, the gridlock that has prevented reform will be perpetuated.

Jacob Hacker is correct when he states that we need to intensify our coalition building. But he also states that “this approach lacks much in terms of conceptual and policy clarity or the inspiration that David Himmelstein provided us earlier today about the sort of large scale reforms we need.” Also, “In my view that means a much stronger clarity about ends but much greater willingness to compromise on means.”

Those who insist on unity behind political means while suppressing clarity about policy ends will not be successful in coalition building, and clearly that is not Jacob Hacker’s intent. Those of us who insist on clarity about policy ends will be there to be certain that efforts to compromise on means will be an honest, transparent, and fully informed process.

New Hampshire Presidential Primary Televised Health Care Forum

For Immediate Release:

For more information contact:
Dr. Gary Sobelson – NH Medical Society
Ed Helm (727) 637-8362
Josh Peletier (603) 320-9569

HQ: 416 Chestnut St., Manchester, New Hampshire, 03101
January 3, 2008, MCAM (Channel 23, in Studio) 3:30-5:30 PM
540 N. Commercial Street, Manchester New Hampshire

The NH Medical Society announces, along with other NH civic organizations, a televised Forum on the timely topic of where the Presidential Candidates stand on changing US health care, on Thursday, January 3, 2008 at the MCAM Studio from 3:30-5:30 PM at 540 N. Commercial Street, Manchester New Hampshire.

With health care issues the top and most important domestic issue and concern of New Hampshire voters, MCAM (Manchester Community Access Media; Chan. 23) will air and distribute a two hour, live, televised Forum on Thursday, January 3, 2008 from 3:30 to 5:30 PM. The exclusive focus of the Forum with be on Presidential candidate health care proposals and how they compare and contrast. The program will be distributed over the internet via www.mcam.org/mcamtv.htm where it will also be archived and available in the future via the internet.

The NH Medical Society, an inintial co-sponsor of Forum, is represented in the Forum by its former President, Dr. Gary Sobelson who has served as the Chair of the Advisory Committee for the Forum. Dr. Sobelson, in announcing the Forum, stated that,

“The public and the press have begun to really focus on understanding the real differences among the Presidential Candidates on their health care proposals. Recently, a major newspaper’s editorial commented that “Americans are increasing frustrated about the subpar performance of this country’s fragmented health care system, and with good reason.” The newspaper concluded that the “Presidential candidates should be talking about the need for universal health coverage and ensuring that Americans have quick access to a primary care doctor.” Our Forum will help New Hampshire citizens hear the three or so major types of proposals being offered, what they mean and where citizens can find more information about the candidates’ positions on health care changes such as the Kaiser Family Foundations’ www.health08.org. What’s more, the candidates will hear from our citizens and the public through this forum.

Forum Summary

* January 3, 2008, non-partisan, educational, televised Forum in Manchester on Presidential candidate health care proposals to be produced in the MCAM (Manchester Community Access Media) studio from 3:30 PM to 5:30 PM, at 540 N. Commercial St. in Manchester, NH, 03101. The program will be re-broadcast on MCAM (Chanel 23, Manchester NH) on Sunday, January 6, 2008 at 4:00 PM and again at 7:30 PM as well as on Monday, January 7, 2008, at 7:30 PM. A majority of the Public Access Centers around New Hampshire have committed to airing the Forum. Additionally, the MC for the Forum, the host of “Political Chowder,” Ms. Arnie Arnesen, expects the 40 stations which air her program to also re-broadcast the Forum.

* Sponsored by Granite State Physicians for a National Health Program and Co-sponsored by the NH Council of Churches, NH Medical Society, Democracy for New Hampshire, NH Academy of Family Physicians, WMD, NH Citizens for Health Care Freedom, and a number of other New Hampshire civic organizations including Democracy for New Hampshire, WMD (Women Making a Difference) and the NH State Association of Letter Carriers.

* Ms. Arnie Arenson, the MC of the Forum, will be assisted by a distinguished panel who will help analyze the Presidential Candidates’ statements and positions. This panel is led by Dr. Gary Sobelson, former Chair of the NH Medical Society and Chair of the Advisory Committee to the Forum. Other panelists include Ms. Maggie Mahar, author of Money Driven Medicine, Dr. Tomas Claremont, GSPNHP leader and NH family practice physician, and Mr. Charlie Arlinghaus, President of the Concord NH Joshia Bartlett Center for Public Policy.

* Public and citizen participation will help focus the Forum on issues important to them and citizens throughout New Hampshire who will “present” in Medical Society style a range of conditions from the uninsured to those unhappily ‘locked’ in jobs because of health care to how market and preventative health care efforts help and/or hinder the health care system.

The purpose of the MCAM televised Presidential Candidate Forum on Health Care is to help the public hear those candidates talk about their position through pre-taped presentations and submission.

The Presidential Candidates have been asked to respond to these four questions:

1. Summarize your proposal for health care change and identify why it should be seen as better than other candidates’ (one minute)–(also please provide source(s) of additional information about you proposal, e.g., website(s), books, etc. that we can post and identify);

2. How would you provide health care for the 47 million Americans who have no health insurance; how much will your plan cost; how will you pay for it? (two minutes; include ‘more info on’ [website etc.]),

3. In the present American health care system, close to one out of every three dollars does not go for healthcare but rather “Administrative Expenses,” i.e, advertising, profits, etc. with paperwork costs amounting to 16% alone. Discuss your view of whether health care is a right or privilege, service or business, profession or marke t enterprise (one and half minute; more info etc.). And,

4. Why is the United States the only industrial country in the world that permits drug companies to advertise on television and does not have national health care for all its people (30 seconds; more info etc.) Or, the US now spends more per person on health care than any other nation but in most rankings of our health care system, we don’t have the best health care. In fact, we usually come out about 5th or lower in the quality rankings. What would you do to fix this?” (30 seconds; more info etc.)

Representatives of Presidential candidates have been invited to respond to questions about health care issues and their Candidate’s health care proposals.

Dr. Matthew Masewic
(603) 856-7121
Chair Designate GSPNHP

Dr. Gary Sobelson
(603) 225-3427
Chair, Forum Adv. Com.

Edward Helm
(727) 637-8362
Assistant to Chair GSPNHP

Most Free Drug Samples go to the Wealthy and Insured

Contact:
Sarah L. Cutrona, MD, MPH
Steffie Woolhandler, MD, MPH
David U. Himmelstein, MD

Harvard Study Says Samples are a Not a Safety Net Despite Drug Company Claims to the Contrary

Click here to read the study.

Most free drug samples go to wealthy and insured patients and are not used to ease the burden of the poorest nor the uninsured, according to a study by physicians from Cambridge Health Alliance and Harvard Medical School. The study, which is the first to look at free drug samples nationally, will appear in the February, 2008 issue of the American Journal of Public Health.

The study found that use of free prescription drug samples is widespread. More than one out of every ten Americans received one or more free drug samples in 2003. Among Americans who take at least one prescription drug, nearly one out of five got free samples.

Few free samples went to the needy. Insured Americans and those with higher incomes were more likely to report receiving at least one free sample. More than four-fifths of sample recipients were insured all year. Conversely, less than one-fifth were uninsured for all or part of 2003, and less than one-third had low incomes (under $37,000 for a family of four.)

Free sample receipt was consistently higher among those with better access to medical care. Non-Hispanics, English-speakers and Whites were all more likely to receive free samples than were members of ethnic, linguistic or racial minorities. Receiving medical care in an office and taking more medications also increased the chances of receiving free drug samples.

Author Sarah Cutrona, a physician at Cambridge Health Alliance and an Instructor of Medicine at Harvard commented: “The distribution of free samples has become controversial. Evidence shows that free samples may influence physicians’ prescribing behavior and cause safety problems. For instance, we found that the most widely distributed sample in 2002 was Vioxx, with Celebrex being number 3. These drugs turned out to have lethal side effects. While many doctors still view samples as a safety net for their neediest patients, our study shows that samples are potentially dangerous, and do little for the needy.”

Senior co-author David Himmelstein, a primary care physician and an Associate Professor of Medicine at Harvard adds: “Drug companies usually decide which medical office gets which free samples. They distribute samples according to their marketing needs, not our patients’ needs”

“Free drug samples are not the solution to the disproportionately low amount of health care resources going to the poor and uninsured; they are part of the problem,” said Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard and study co-author.