Dr. Don McCanne editorial in the San Diego Physician (PDF File)

Originally Published 4/4/2006

Countries that have national health services easily accessible to people of all ages are more likely to have better survival rates for their teenagers and young adults (TYAs) with cancer, than are countries where individuals have to pay for their own medical insurance.

This is the suggestion that arises from new research presented at the 4th International Conference on Teenage and Young Adult Cancer Medicine, in which the health care systems of the United States of America and Australia were compared.

Professor Archie Bleyer told the conference, organised by Teenage Cancer Trust, that Australia’s system of health insurance for all, regardless of age, meant that TYAs were more likely to survive cancer in Australia than they were in the USA.

Prof Bleyer, who is medical advisor at the Cancer Treatment Center, St Charles Medical Center, Bend, Oregon, said: “However, both countries have a lower survival rate for their TYAs than for their younger and older patients, proving that TYAs remain the most neglected group of cancer patients across the globe.

“Our previous research has shown that the survival of older teenagers and young adults with cancer in the United States has lagged behind progress in younger and older patients. We found that diagnosis was delayed in TYAs who either lacked health insurance or had inadequate insurance, and therefore this lack of progress might be due to the USA health care system and less expected in countries with national health insurance.

“During the past year we have compared survival of TYAs in the USA with those in Australia, a country similar in many demographics to the USA, but with health insurance provided to all citizens regardless of age.

“From 1982 to 1998, the rate of improvement in the five-year survival from invasive cancer in Australia exceeded that which occurred in the USA, such that by the late 1990s, TYAs in Australia had an overall five-year cancer survival that was higher than in the USA. The deficit begins at 16 and ends at 55, the same years that national health insurance is not available in the USA. It ranges from 5% for 18 to 25 year-olds to 12% for those aged 30 to 35. This difference suggests that the health care system in Australia, with universal health insurance, was able to provide better cancer care to its TYAs.

“The advantage for Australian TYAs was not apparent in their children or older adults with cancer. This suggests that the need for private health insurance in the USA is responsible for the worse survival of TYAs, in that children and older adults in the USA are more adequately insured than TYAs.”

In the USA the greatest improvement in survival occurred amongst patients aged over 65 for whom national health insurance is provided.
Prof Bleyer said: “Both countries, however, had a lower rate of improvement in the five-year cancer survival rate among TYAs than in either younger or older patients, albeit the relative deficit was greater in the USA than in Australia.

“These comparisons indicate that the relative lack of progress in cancer outcome among TYAs in the USA is due, at least in part to the lack of health insurance,” he said.

However, he warned that even in countries where there was national health insurance for all, this didn’t necessarily guarantee access to good diagnosis and treatment for cancer patients, and particularly not for TYAs.

“Good health care systems make a huge difference in prolonging survival and reducing deaths amongst TYAs with cancer,” he said. “The failure to improve survival amongst 15 to 29-year-olds over the last quarter of a century is striking and there are reasons that are common between different countries. These include the tendency for adolescents and young adults to wait longer before consulting a doctor about symptoms, lack of a regular and usual source of primary care, delays in diagnosis by doctors not used to seeing young people with cancer, the wide spectrum of cancers contracted by TYAs, physicians poorly trained in caring for TYAs with cancer, and, most importantly, the lack of participation in clinical trials for this age group.”

Some countries belatedly were waking up to this problem, he said. In the UK, the National Institute for Health and Clinical Excellence (NICE) issued new guidance for the treatment of under-19s in August 2005. “In the USA the National Cancer Institute has initiated a major review of the national status of cancer in this age group. Known as a Progress Review Group, the nation’s experts will evaluate all available data, determine the severity and potential solutions, and provide an official report of recommendations,” he said.

“In addition, the President’s Cancer Panel is working on a similar report on the survivorship of young Americans with cancer. Both efforts include a review of the role of health insurance and health care delivery systems in the new medical frontier that is TYA oncology.”

The New York Times
Published: April 9, 2006

To the Editor:
Your reports about Massachusetts’ health reform legislation treat politicians’ overblown claims as gospel.

The legislation completely ignores one-third of the uninsured, dismissing the Census Bureau’s estimate that 748,000 lack coverage in Massachusetts in favor of an estimate of 500,000 derived from a phone survey.

The linchpin of the promised coverage is a requirement that most of the uninsured buy their own coverage, and assurances that private insurers will offer affordable, comprehensive policies.

But already reports have surfaced that these new policies will be far costlier than promised, putting them out of reach of most of the uninsured and sharply raising the costs of state subsidies to help the very poor.

Predictably, rising costs will force more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. When the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation.

The program is simply not sustainable over the long or even short term. In contrast, a single-payer reform could save $9 billion a year on bureaucracy in Massachusetts, more than enough to cover the uninsured and to upgrade coverage for the rest of us.

David U. Himmelstein, M.D.
Steffie Woolhandler, M.D.
Cambridge, Mass., April 6, 2006
The writers, associate professors of medicine at Harvard, co-founded Physicians for a National Health Program.

Originally Published April 8, 2006

Des Moines Register Editorial Board

On Tuesday, the Massachusetts Legislature passed a bill mandating all residents purchase health insurance. The philosophy is right: Everyone should have health insurance. It should be affordable. When people are uninsured, everyone pays.

But it’s difficult to get too excited about what Massachusetts did to cover its roughly 550,000 uninsured residents. The bill requires businesses to offer insurance or face financial penalties, but it doesn’t guarantee that insurance be adequate. Individuals must buy insurance or face tax penalties, but it doesn’t define what “affordable” health insurance means. It expands health care for lower-income residents, but much of the money comes from shuffling
existing dollars.

Worst of all, it mandates residents participate in a dysfunctional system that largely ties health care to employment. Every other industrialized country in the world knows it’s a bad idea to tie health care to jobs. It kills entrepreneurial spirit, saddles business with huge costs and forces employers to choose between their bottom lines and the best health policies for workers.

The Massachusetts bill also funnels even more dollars to private insurance companies that may waste money on administration. According to a 2003 Harvard Medical School study, nearly one-third of all U.S. health-care expenditures goes to administration and bureaucracy. That includes insurance-company paper pushers and all the people doctors offices employ to navigate the thousands of insurance plans.

Massachusetts Gov. Mitt Romney, who is considering a run for president, has boasted that the plan gets everyone covered without new taxes or a government takeover.

Yet when it comes to health care, the government is hardly the enemy. Indeed, it may be the best hope.

Medicare provides uniform coverage with low administrative costs for more than 40 million seniors and disabled people. Though it needs some fixing, a Medicare-like system for everyone would be more efficient and use fewer dollars on administration than private insurance.

Given the inaction on health-care reform at the federal level, state legislatures are trying to take on the job. While the desire by Massachusetts lawmakers to cover everyone is philosophically right, the approach isn’t.

The fix has to come from a different group of lawmakers – the ones in Washington.

By Dr. Susanne L. King
Berkshire Eagle

Tuesday, April 11

LENOX

MANY PEOPLE have been cheering the new health care bill that was passed by the Massachusetts Legislature, which is supposed to provide universal health care coverage for our state. The bill has three provisions to expand health care coverage to the uninsured. The first is to expand Medicaid eligibility, by allowing more people to qualify for this government program. The second is to offer government subsidies to low-income individuals. And the third is to require those making more than three times the poverty level (about $30,000 for a single person), to buy insurance or pay a fine. The politicians want us to believe that this is a home run, but I am not cheering.

Extending health care to the uninsured so that everyone is covered (universal health insurance) is an important aspect of health care reform. However, it is unclear whether this bill will be able to achieve that goal. In addition, universality is only the first of the five criteria proposed by the Institute of Medicine for health care reform. The other four criteria are not addressed in the current bill: that health care be continuous, i.e., not tied to a job (2); affordable for individuals and families (3); affordable for society (4); and equitable and patient-centered (5).

Politicians have assumed that only 500,000 people in Massachusetts are uninsured. However, the Census Bureau reports 748,000 uninsured, 50 percent more people than were counted in the Legislature’s figure-crunching for the bill. That leaves out a lot of people from the new bill, or costs a lot more money than the Legislature anticipated.

Since health care insurance will still be tied to jobs with this health care bill, it is not possible for it to be continuous. One of the thrusts of the current legislation is to make businesses accountable in supplying health care insurance to their employees. When your health care insurance is tied to a job, it is not portable if you change jobs; and you are forced to change insurance if your employer shifts to a different carrier.

Is the current legislation affordable for Massachusetts? The funding for the bill is nebulous. The state hopes to retain the federal Medicaid dollars that were in jeopardy without an expansion of coverage, but that is a small portion of the current $59 billion health care budget, which is estimated to increase by $25 billion over the next three years. Businesses with more than 10 employees may have to pay $295 per employee if they don’t offer insurance, but Medicaid hikes to hospitals (provided in the bill) will triple the amount garnered from businesses. And the bill projects savings from “market reform” and patients being treated in doctors’ offices instead of emergency rooms. These savings may be imaginary.

Another false assumption is that people will be able to buy affordable insurance. None of the insurance companies have yet offered such plans, but the estimate from the Statehouse is that these low-cost plans may set an individual back about $325 a month. Along with the insurance plan deductible allowed by the legislation, this would work out to more than 20 percent of the income from an individual making $30,000, scarcely an affordable plan.

Is this legislation equitable and patient-centered? Patients still will not have their choice of doctors or hospitals: the insurance plans will continue to dictate who you can see and where you can go for your health care. The promises that the uninsured would be offered comprehensive care through this legislation is also an empty one: the only way to get cheaper plans, and still maintain insurance company profits, is to boost deductibles and co-payments, and provide fewer covered services. Comprehensive coverage is not a feature of this bill. It remains to be seen what devastating gaps will be created. Equitable insurance would be for everyone in the state to have the same health care benefits that our elected representatives have.

Finally, is this legislation affordable for Massachusetts? It does nothing to contain the skyrocketing costs of health care in our state. Instead, it gives new infusions of cash to the private insurers and some big hospitals. The Boston Globe reported that lobbyists for insurance companies, some hospitals, and other major players in the health care industry were paid at least $7.5 million in 2005, as the Legislature took up this bill. This is not health care reform: this is business as usual for the private health care insurance industry.

And as usual, the insurance industry will not just maintain, but will increase, its profits. The American Medical News reported that health plans made more money, and spent less on health care in 2005, than in previous years. While the insurance companies make money providing coverage for the healthy workforce and their young healthy families, we taxpayers foot the bills for those segments of the population with greater health care needs.

If we were to take the $9,100/ year per person that we spend in Massachusetts (more than any state or country in the world), and use it for health care rather than insurance company profits, we would be able to provide truly universal, affordable, continuous, equitable and comprehensive care to the citizens of the commonwealth. We need a single-payer health care system, in which the government collects and administers the funds for health care, eliminating the insurance company middlemen.

That would be a spectacular home run for the state of Massachusetts.

for a printable pdf version of this letter (click here)
for a fact sheet on the Massachusetts bill (click here)

Governor Mitt Romney
State Capitol
Boston, MA 02133

November 3, 2005

Dear Governor Romney, Speaker DiMasi and Senate President Travaglini:

We urge you to abandon your ill-conceived proposals for health care reform and to adopt, instead, a single payer program of universal coverage for the Commonwealth.

As physicians and health professionals, we witness the heavy toll of unnecessary suffering endured by patients who delay care and even forego vital treatment due to costs. While the uninsured bear the heaviest burden, many with insurance also find care unaffordable due to co-payments, deductibles and restrictions on coverage. Reforms should address the grave problems of both groups.

Your plans to loosen regulations on health insurance, allowing ever-skimpier coverage, would perpetrate a cruel hoax. Such cut-rate policies would cost families thousands of dollars yet offer miserly care and little protection from financial ruin in the face of serious illness. Many who currently enjoy adequate coverage would doubtless be forced into plans with gaping holes and onerous restrictions on choice. If there is one thing worse than being uninsured it’s paying dearly for worthless coverage.

Your view that we can achieve universal coverage by forcing people to buy themselves insurance ignores the most basic facts about who is uninsured. Only 12.4% of the 748,000 uninsured in our state are both young enough to qualify for low-premium plans (under age 35) and affluent enough (family incomes greater than 499% of poverty) to readily afford them. Yet even this 12.4% figure may be too high if insurers are allowed to charge higher premiums for persons with health problems; only half of uninsured persons in those age and income categories report that they are in “excellent health” (The statistics in this paragraph were obtained by analyses of data that the Census Bureau collected on Massachusetts residents in March 2005).

Proposals to raid the existing free care pool in order to partially subsidize cut-rate policies would actually worsen the plight of many who are currently uninsured. Under such reforms, patients now eligible for free or low-cost services would often face greater restrictions on care and higher out-of-pocket costs. The only real winners would be the private insurers who would surely gain millions from the sale of near-useless policies.

Replaying Dukakis’ failed employer mandate, i.e. making employers pony up more money for coverage, will not lead to universal coverage. As Dukakis found, relentlessly rising health costs quickly stir rebellion among powerful employers, making the program unsustainable.

While we welcome the expansion of Medicaid as a stopgap measure to cover more poor families, we know that this strategy ultimately leads to a dead end. Inevitably, the next economic downturn will bring a flood of additional families pushed onto the Medicaid rolls just as state tax revenues fall. As in the past, Medicaid will be cut when the need is greatest.

In contrast, a single payer reform would create a stable long-term financing mechanism for health care. It could cut costs by streamlining health care paperwork, making universal, comprehensive coverage affordable. The Commonwealth’s three largest private insurers spend more than $1.3 billion annually on billing, marketing, high executive salaries and other administrative costs. That’s ten times as much overhead per enrollee as Canada’s national health insurance program. And hospitals and doctors spend billions more fighting with insurers over payments for each aspirin tablet, x-ray and doctor’s visit. If we cut bureaucracy to Canada’s levels we could save at least 14% of current health expenditures, enough to cover all of the uninsured in Massachusetts and to improve coverage for the rest of our patients as well.

And single payer is popular. Sixty-two percent of Massachusetts doctors support it (according to a recent study in the Archives of Internal Medicine), joining the Massachusetts Nurses Association and dozens of other labor, seniors and consumer groups.

We recognize that a single payer reform threatens the multi-billion dollar insurance industry, and would force down the high profits enjoyed by drug companies. But such interests must not be placed ahead of the health of the people of Massachusetts. Only a single payer system can assure universal and comprehensive coverage at an affordable price. The people of the Commonwealth deserve no less.

Sincerely,

Dr. Nancee Bershof, Greenfield
Dr. J. Wesley Boyd, Cambridge
Dr. John Day, Boston
Dr. Tina Furcolo, Springfield
Dr. Kathleen Grandison, Shelburne Falls
Dr. Audrey Guhn, Springfield
Dr. David Himmelstein, Cambridge
Dr. Mike Kaplan, Lenox
Dr. Suzanne King, Lenox
Dr. Sarah Kremble, Leyden
Dr. Richard McGinn, Greenfield
Dr. Kathleen McGraw, Montague
Dr. George Milowe, Malden
Dr. Ruth A. Potee, Boston
Dr. Vikas Saini, Hyannis
Dr. John Walsh, Worchester
Dr. Steffie Woolhandler, Cambridge

And The 290 Undersigned Massachusetts Physicians

For a fact sheet on the bill, click here

Letter to the Editor
Huntsville Times
Published Monday, March 27, 2006

The Association Health Plans proposed by President Bush and now being considered by Congress will not be of any help to middle-class and working families. It is a plan for the rich who can already afford health care.

Here is what it would do:

Increase the number of uninsured by up to a million workers.

Increase premiums for 86 percent of small businesses.

Deny coverage to older and sick people.

Dodge state coverage requirements, like childhood vaccinations.

Allow exemptions from mandated benefits, like cancer screening.

Eliminate our power to appeal rejected claims.

Hard-working families need relief from the rising costs of health care, not a plan making our insurance less affordable, less accessible and less secure.

We refused to let Bush “privatize” Social Security. We can refuse to let him mess up the health care we have.

What we need is a single-payer, national health care system that covers everybody.

It’s shameful that one-fifth of our population have no health care.

Reese Danley-Kilgo
Huntsville, 35802

Opinion
Daily Gazette, Schenectady, NY
Published Sunday, March 26, 2006

Advocates of a new state law that would mandate medium- to large-sized employers to pay for their workers’ health insurance have cause to be frustrated by the status quo in health care: It’s an inadequate system that in New York alone has pushed hundreds of thousands of low-wage workers onto the Medicaid rolls and left even more without any insurance. Still, their pro posal would be ruinous for thousands of New York businesses, and driving them into bankruptcy or across state lines would hardly do the working poor – or state and local governments – much good.

The bill would be incredibly expensive, forcing businesses to pay $3 per working hour for each employee. Some of these workers – in the retail sector, for example – may only be making $8 or $9 an hour; so the bill would effectively raise their employers’ payroll costs by a third. In a competitive business world, that kind of hit could be fatal. If the business were near a border and had to compete across state lines, for example, they couldn’t raise prices enough to cover their costs. And even if they could, would the resulting inflation be good for the economy?

In addition, the bill would be a disincentive for small- to medium-sized companies – those with fewer than 100 workers – to keep growing, lest they crossed the threshold and had to start paying for health insurance.

Health insurance is an enormous burden on whoever has to pay for it – individual, employer, employee or government. While ideally, all employers would offer their workers some coverage, the idea of forcing them to is flawed – especially when the plan would be so expensive and when only certain employers would have to go along.

It pretty much has to be an all-or-nothing proposition, and all is clearly preferable. But to be done properly, it should be offered by a single payer – the U.S. government – which would allow far greater economies of scale than any other option.