PNHP

Interview with Dr. David Himmelstein

Interview with Dr. David Himmelstein

Healthcare for All: The Campaign for Single-Payer Health Insurance in Massachusetts and the United States
Multinational Monitor
Originally published December 2000
Volume 21, Number 12

INTERVIEW

David Himmelstein is an associate professor of medicine at Harvard Medical School and co-founder of Physicians for a National Health Program. The author of numerous studies and books, he is a leader in the movement for universal health care. He was also an author of the recently defeated Question 5, a Massachusetts initiative that would have delivered universal health care for the citizens of the Commonwealth.

Multinational Monitor: Why does the United States need universal health care?

David Himmelstein: Forty-three million people in the United States have no health insurance at all, and tens of millions more have such inadequate coverage that if they were seriously ill, they would be bankrupted. Millions of Americans don’t get the care they need. And simultaneously, we are throwing away huge resources on useless bureaucracy, outrageous profits, outright fraud and unnecessary overtreatment for many patients. We need a thorough revision of our system to deliver the care to the people.

We now have the most expensive health care system in the world. We pay money to middlemen – private insurance companies and HMOs – who do nothing useful. These private insurers act on behalf of employers to limit care to patients and simultaneously extract profits for themselves and other health care providers.

MM: But the insurance companies do provide coverage to tens of millions of people in the United States, right?

Himmelstein: They pass some of the money paid in premiums along to the doctor or to the hospital, but they charge an extraordinary fee for doing that. The average private insurer in this country takes about 13 to 14 percent of the total premium dollar for their overhead.

By contrast, Medicare runs for about 2 percent overheard. The Canadian national health insurance program runs for less than 1 percent overhead.

In the sense that the private insurance companies spread risk and carry out the insurance function, that’s a useful function. But they do it in an extraordinary inefficient way that enriches themselves and their business partners.

MM: You support a Canadian-style single payer system?

Himmelstein: Right, but a national health service like Britain’s would be fine, also.

MM: What’s the difference between Canadian and British systems?

Himmelstein: Canada has provincial health insurance plans. In each province, everybody is covered under a single government-run health insurance plan. You pay your taxes, and your taxes go to cover everybody. That plan then negotiates with all of the hospitals in the province on what each of their budgets is going to be. Instead of paying for hospital care band aid by band aid, aspirin tablet by aspirin tablet, they negotiate with the hospital their entire budget for the year, and they pay them one check a month for that budget.

Doctors submit all of their bills to the public plan, and get paid on a fee-for-service basis. The fees are negotiated between the doctors and the provincial health plan.

In Canada, the doctors have remained in private practice, though they are paid by the public system. Hospitals have remained mostly private, although again, they receive their payments from the public insurance system.

In Britain, the hospitals are owned by the government. The specialists are employed on salary by government as employees of the hospitals.

MM: Why not fix the system here in the United States?

Himmestein: We ought to fix the current system, but there is nothing that will work short of national health insurance.

We have had a series of patchwork reforms over the last 20 years now, and we have more uninsured people today than we had 20 years ago. And despite the economic boom, we have made no dent in the number of people who are uninsured.

We passed the children’s health insurance program two or three years ago, but there are as many uninsured children now as there were two or three years ago, because health care costs keep rising, and fewer people can afford private coverage. The public expansions don’t keep pace with the cutbacks in private coverage most years.

Basically, as a private insurance firm, the way you make money is to avoid sick people. There has been no effective way of policing that.

The problem is that unless you require that either an employer buy coverage for an employee, or that an individual buy coverage, there is no way of making universal coverage in a private insurance system. Moreover, poor people are least likely to be able to afford medical care, and are often the sickest people in the society.

MM: How many uninsured people are there in the United States?

Himmelstein: Forty three million – that’s about 15 percent of the population.

MM: What happens when an uninsured person gets sick? Who pays?

Himmelstein: It depends on where they are and exactly what they are sick with. It varies from community to community. If you are sick enough to be in imminent danger of dying, then a hospital is required to stabilize you or risk a fine from the federal government. Several dozen hospitals get that kind of fine every year, so it does happen that even very sick people are denied care.

If a hospital treats an uninsured patient, the hospital tries to collect from you, and if they can’t collect from you, then they write it off as free care. In some states, there are some state funds available to subsidize that care, in others not. In some cities there are some public hospitals available to help subsidize that care and others not.

If you are not very ill, in some places, you may not be able to get any care. In other places, there are some systems of care for the uninsured, either locally subsidized or at reduced rates.

There are 300,000 people refused care in hospital emergency rooms every year because they can’t pay.

MM: Under a system of national health insurance, what happens to the insurance companies?

Himmelstein: They are eliminated.

The total health budget in the United States is about $1.2 trillion. About $300 billion is administration, and you could probably eliminate about $175 billion of it with rational health insurance system.

It is very clear that if you streamline the system and took the administrative waste out of it, you could give Cadillac care to everybody in the country for what we are now spending. The General Accounting Office has studied the question, and confirmed that. The Congressional Budget Office found that. A right-wing consulting firm made estimates that are in line with that.

MM: Can national health insurance supporters in the United States overcome public distrust of government?

Himmelstein: Most Americans have some distrust of government. One of the organizations they like even less than government is private insurance companies. And those are the only two options for running our health insurance system.

Surveys show that universal coverage is enormously popular. If you give a reasonable description of a Canadian-style health care system, about 55 to 60 percent say they support that.

MM: So why doesn’t the United States have a national health insurance system?

Himmelstein: First, national health insurance means a major redistribution of income. At present, the poorer you are, the larger the proportion of your income you spend for medical care. And if you go to a tax-funded national health insurance plan, presumably you are going to fund it out of a vaguely progressive tax. And rich people are going to pay a higher proportion of their income and poor people are going to pay a lower proportion of their income. It implies a substantial redistribution of income.

Second, national health insurance attacks a major concentration of corporate power. Some of the largest and richest firms in the country are health care firms. You are putting out of business HMOs and health insurance companies.

And you are severely affecting the profits of others. The drug industry, which has been the most profitable industry among the Fortune 500, would be faced by a single national purchaser of their drugs. And they wouldn’t get away with the rip-off prices that are routine for them now.

The government will say to the drug companies, “We are not willing to pay for the $12 billion a year that you spend to miseducate doctors.” That’s the marketing and sales force, which they would presumably have to justify as a cost, if they were bargaining with the government. The drug companies would not be in a position to justify those costs.

MM: Question 5 was a universal health care proposition on the ballot in Massachusetts in November. What would it have done?

Himmelstein: It would have done three things.

First, it would have required our state legislature to pass universal coverage by July 1, 2001 and implement it by July 1, 2002. The system was required to eliminate barriers to care. It had to maintain a free choice of provider for patients. It had to minimize incentives for overcare and undercare.

Question 5 didn’t specify how universal coverage should have been carried out. And clearly, if it had passed, there would have been a major debate in our state about exactly how to do it.

It would have set up a commission to advise the legislature on how it ought to have been done. And on the commission would have been several advocates of a Canadian single payer system.

MM: Why weren’t you explicit about how the single payer system would have worked?

Himmelstein: Under the laws in Massachusetts, you can’t appropriate money with a ballot initiative. We couldn’t actually put in place a new tax structure to fund health care and specify that degree of detail. Second, specifying a system in detail would have required many pages of detailed text. We knew we were going to be tremendously attacked by the insurance industry and others. And we thought that the possibility of having a reasonable debate about the detailed structure of the system was almost nil given the political system in our state.

For tactical reasons, we decided that the first step was to say, “There needs to be universal coverage, and here are some broad outlines. Let’s set up a commission that includes a majority of single payer advocates. And then within six months, let’s proceed to the next step.”

There were two other clauses. One would have banned conversions of hospitals and HMOs to for-profit businesses. The other would put in place some restrictions on HMOs immediately. They would have to spend at least 90 percent of premiums on medical care. It would also have required them to allow patients to go to any doctor licensed in the state. And it would have outlawed financial incentives to doctors to restrict care.

MM: Who in the state supported Question 5?

Himmelstein: Question 5 was initially proposed by an ad hoc group of doctors, nurses, psychologists and other health professionals. We went around and started to build a broader coalition with some friends and colleagues who had some more political sophistication that we did.

They rounded up a number of groups that were going to support it, including the AFL-CIO and some consumer advocacy groups including Health Care for All, which has Families USA as its Washington, D.C. counterpart.

The groups collected the signatures to get the thing on the ballot – 120,000 signatures. Those signatures were collected last fall. And this spring we collected another 15,000. Under Massachusetts law, you have to collect two sets of signatures.

The legislature started to panic about this initiative being on the ballot. And the HMO industry did as well.

A patient protection bill, which had been stalled by the HMO lobby in the legislature for three years, suddenly began to move. And it was clear the HMOs had instructed the legislative leaders that they needed that thing to pass, and they wanted the ballot initiative to be removed. A last minute deal was struck between the HMOs and the major groups that had signed on to the initiative. The patient protection bill would become law and in exchange, the initiative would be pulled off the ballot at the last moment.

That left only the League of Women Voters and the original ad hoc group of doctors, nurses and other individual professionals supporting it. We were left with no organization, no money and little political savvy.

MM: What did the patient protection act do?

Himmelstein: It put in place the right to appeal if an HMO denied you care. It put in place a structure to regulate for-profit conversions of hospitals and HMOS. It set up a commission to advise the legislature on universal coverage, although there was no mandate that the legislature had to do anything about it.

We rejected the deal because the patient protection act was more or less the same reforms they put in place in 30 other states, and those laws have had no noticeable effects on health care in those states. Instead of prohibiting conversions, it laid out how an HMO or hospital could be converted to an investor-owned organization.

Third, it set no deadlines, and no requirement for universal coverage. It just set up a commission that was not likely to act. So, we thought the deal was nothing but a sham and didn’t effectively accomplish anything.

MM: But once on the ballot, the AFL -CIO and Health Care for All could not remove the initiative?

Himmelstein: They felt they could. The negotiations on the deal were being conducted right around the time when the final signatures were due earlier this year. Our allies turned the sheets with the signatures in because the patient protection act legislation was dragging. And they thought they were turning in the signatures as a stick to put over the heads of the legislative leaders to conclude the legislative wrangling.

They turned them in to the Secretary of State. Then they tried to withdraw them. At that point, the rest of us who had been involved said, “No, you can’t withdraw them.” And the Secretary of State ruled in our favor.

MM: So, you get on the ballot. At that point, who was supporting you and who was opposing you?

Himmelstein: Our major supporters were colleagues. The biggest organization was the Massachusetts Nursing Association. The League of Women Voters was important. And individual doctors and nurses. That’s about it.

The opposition was the business community and particularly the HMOs in Massachusetts. The HMOs kicked in at least $5 million. Organizations like Raytheon and some other big businesses kicked in money. They saturated the television and radio airwaves.

MM: What was their argument?

Himmelstein: They argued that this proposal would raise costs tremendously. They commissioned a study that claimed that universal coverage would increase costs by 40 percent in Massachusetts. That is a fairly bizarre notion. We are already 30 percent above the national average in our state.

We are spending $6,000 per capita in Massachusetts on health care. The notion that we would raise that to something like $8,000 per capita is bizarre. There is no place else in the world that spends more than $2,500 per capita on health care. In the United States, we are spending $4,000 per capita.

There is no serious health policy person who believes that under universal health care we would be spending $8,000 per capita. But they commissioned studies that purported to show that and the news media covered those studies as if they were true.

There have been two serious studies of what statewide health insurance program in Massachusetts would cost. Both of those were commissioned by the Massachusetts Medical Society, by no means a left-wing organization. And both concluded that you either save money, or it might increase costs a little in the first year, and then you start to save money.

MM: They spent $5 million, you spent $60,000. They had ads all over the airwaves, you had no ads. You relied on free media. Did you get much publicity?

Himmelstein: A fair amount. The last week or two, when it became clear that we had a serious chance of winning this, the press actually began to cover it. The problem was that the folks working on the campaign for us were doing it in our spare time, after working full-time jobs. And we were not in a position to spend our days thinking up lies to tell, like the opposition was doing.

They would put out a raft of lies, which the press would report, and we would then try and counter those, but by no means have the time or resources to go after each one.

MM: What were you expecting in terms of percentage of the vote?

Himmelstein: We didn’t know what to expect. The polls showed that we were ahead 75 to 25 at the beginning. We thought we would probably go down fairly fast from there, but a week before the election, the polls showed us at 60 to 40. We started to think that we might win it, especially after Senator Ted Kennedy said he was going to vote for it. And during the last week, a few politicians began to filter to the front of the parade, since they apparently thought the thing might pass.

If we had only a minimally competent campaign, it would have passed. We lost in the end 51 to 49.

If we had signs at half the polling places in the state that said – Ted Kennedy says vote yes on Question 5 – we would have won easily. But we weren’t organized enough to do that.

MM: Are you bitter about this?

Himmelstein: No, we are tremendously energized by this. We made every conceivable mistake. We ran the most incompetent campaign possible. We were deserted by all of our allies.

And we still got 49 percent of the vote. We feel like all we need to do is do this right and we will win easily.

MM: Do you plan to do it again?

Himmelstein: Yes, in 2002.

MM: When is the United States going to get universal health care?

Himmelstein: We are going to have a major debate about this in the next three or four years. When we are going to get it is more difficult to say. We’ll have opportunities for it in a major way. The system is becoming unstable. Costs are rising very rapidly. In the early 1990s managed care firms said to employers, “We will hold down your costs if you give us control of the system.”

From 1994 to 1997, health care costs rose more slowly than they did in the late 1980s and early 1990s. And big employers closed ranks behind the existing health care system. While patients were dissatisfied, the system was fairly stable at that point.

Now, you have the re-emergence of health care inflation. And that is a major destabilizing force. Now it is clear that HMOs have not succeeded in containing costs and are not likely to. We are going to have to have some other major reform of our health care system to contain costs.

That creates divisions in corporate America and allows for an opening for debate that otherwise is difficult to create. The implementation of HMO control of the system in the early 1990s was quite brutal, not only for uninsured patients but for many insured patients. That spread a reaction among not just the poor, but many middle class people who are now dissatisfied with the system.

It creates an opportunity for a broad coalition for change. Surveys show that something like 55 to 60 percent of doctors now are in favor of national health insurance. The majority of all medical school deans in the United States have explicitly endorsed single payer health insurance.

MM: Why isn’t that support being translated into political support in Washington?

Himmelstein: No firm in the U.S. has ever advocated the nationalization of any industry. General Motors is upset that its health care costs are going up, but they are not yet ready to say that the preferred solution is the elimination of a private capitalist industry.

MM: Has legislation been introduced in Congress?

Himmelstein: Yes, regularly since 1948. But it never goes anywhere. In the early 1990s, 70 or 80 members of Congress supported it. Now there are about 20 or 30 members who actively support it. If there were a serious organizing effort, we could get back to 50 or 60 members supporting it.

But, the Congress is going to be the last place to act. We are going to need to create a major groundswell for change before Congress acts.

Medicaid's Health Opportunity Accounts

Medicaid to offer HSA pilot program
By Amy Snow Landa
American Medical News
March 13, 2006

Health savings accounts aren’t just for the private market anymore.

President Bush has signed legislation that will allow up to 10 states to offer Medicaid recipients “Health Opportunity Accounts” that are similar to health savings accounts available in the private market.

The provision allows participating states to test whether HOAs encourage Medicaid recipients to be more cost-conscious about their health care decisions by giving them a stake in their health care spending.

“That’s especially needed in Medicaid, because people on Medicaid have had very little exposure to the actual cost of their health care consumption,” said Grace-Marie Turner, president of the Galen Institute, a health policy research organization in Alexandria, Va., that advocates for consumer-driven health care.

HOA enrollees who leave Medicaid can use their remaining account funds to pay for health care services or coverage, or even job training and tuition expenses.

That makes sense, said the Galen Institute’s Turner.

“If you don’t need the money for health care, allow people to use the money for something they value — that’s part of the savings incentive,” she said.

The federal program is limited to 10 states in the first five years, but the secretary of Health and Human Services is allowed to extend the program nationwide after the five-year period ends. If that occurs, the program’s costs will triple over the second five years to a total increase in federal Medicaid spending of $265 million over 10 years, the CBO estimates.

http://www.ama-assn.org/amednews/2006/03/13/gvsa0313.htm

And…

Health Opportunity Accounts for Low-Income Medicaid Beneficiaries: A Risky Approach
By Edwin Park and Judith Solomon
Center on Budget and Policy Priorities
November 1, 2005

Conclusion

While the scope of the Health Opportunity Accounts demonstration project is limited for the first five years, the use of such accounts for low-income Medicaid beneficiaries poses a significant risk of reducing beneficiary access to medically necessary services. The Health Opportunity Accounts could leave some beneficiaries, particularly those in poorer health, responsible for out-of-pocket costs related to health services they need when they have exhausted their accounts but not yet met the deductible. These costs would be on top of the standard copayments that beneficiaries would have to pay once the deductible was exhausted, which themselves would be increased by other Medicaid provisions of the Energy and Commerce reconciliation package. Research indicates that increased cost-sharing particularly affects the ability of low-income individuals to access health care.

At the same time, the Health Opportunity Accounts would add to federal Medicaid costs. By allowing former beneficiaries to keep balances held in their accounts, the federal government would essentially be paying for benefits provided to individuals and families no longer eligible for Medicaid. The demonstration project also would permit, at state option, the use of federal Medicaid dollars to pay for health care services not covered under Medicaid and even for non-medical services.

Despite these substantial risks, after five years, the demonstration project would become permanent, and the Secretary of Health and Human Services could extend it nationwide to all states and all beneficiaries, without review and further action by Congress. All of this leads to a conclusion that the demonstration project in the Energy and Commerce Committee’s reconciliation package is seriously flawed in a number of respects and that its enactment would represent neither sound health care policy nor sound fiscal policy.

(Now enacted.)

http://www.cbpp.org/10-26-05health.htm

S.1932, Sec.6082 Health Opportunity Accounts:
http://thomas.loc.gov/ (Enter S.1932, click “Bill Number” and then “Search.”
Click on S.1932.ENR. Click on Sec.6082.Health Opportunity Accounts.)

Comment: By Don McCanne, M.D.

What lunacy!

Is European-style insurance the answer?

Universal Health Coverage Does Not Require Single-Payer System, Op-Ed States
Kaiser Daily Health Policy Report
July 3, 2006

“Many proponents, as well as opponents, of health care reform equate universal coverage with a Canadian-style, government-run, single-payer system,” but “a survey of successful health care systems around the world shows this is an incorrect assumption,” Steven Hill, a director of the New America Foundation, writes in a San Jose Mercury News opinion piece. According to Hill, a number of nations without a single-payer health care system — such as Austria, Belgium, France, Germany, Japan and the Netherlands — provide universal health coverage and quality health care “at a fraction of what we pay” in the U.S. Hill writes that the health care systems in those nations share “many similarities with the recent bipartisan health care legislation passed in Massachusetts that mandates a ‘shared responsibility’ between employees, employers and the government,” adding that the “key difference is that the Massachusetts plan does not include cost controls, which understandably are difficult to enact on a state level.” Hill writes, “The evidence is clear that cost controls are extremely important to any successful health care system,” and “the experiences of the public-private hybrid systems in France, Germany, Belgium, Japan and elsewhere show that it is possible to have your cake and eat it too.” The “take-home lesson for health care reformers is that it is important to expand the debate and recognize that universal health coverage does not mean single-payer,” Hill adds (Hill, San Jose Mercury News, 6/30).

http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=38290&dr_cat=3

From Steven Hill’s Op-Ed referenced above:

The funding for health care in these nations is best described as a “shared responsibility” — employees, employers and the government all contribute a pre-determined amount. Both workers and their employers are subject to mandatory payroll deductions, and government chips in any shortfalls for poorer individuals, depending on income level or employment status.

The contributions from individuals, employers and government are deposited into private insurance funds that are non-profit and government-regulated (sometimes known as Sickness Insurance Funds, or SIFs). Additional private insurance can be purchased for premium services, such as a private room in the hospital.

But here’s the key part: the SIFs sit down at the bargaining table with the government and representatives from professional associations of doctors and health care professionals to set exact fee structures. They negotiate strict cost controls that have prevented expenditures paid by consumers from approaching anywhere near exorbitant U.S. levels. Cost controls are essential to the success of these “shared responsibility” systems.

http://www.mercurynews.com/mld/mercurynews/14937478.htm

Comment:

By Don McCanne, M.D.

Judging from my email, single payer advocates around the nation are quite concerned about this Op-Ed from Steven Hill of the New America Foundation. He suggests that we should dismiss consideration of single payer
and move forward with the “shared responsibility” approach of European-type private insurance funds which he parenthetically acknowledges are Sickness Insurance Funds (SIFs).

Ida Hellander, M.D., Executive Director, Physicians for a National Health Program, in a personal communication provides this helpful insight:

“I think the important thing to note is that the ‘sickness funds’ in France, as in Germany, Switzerland, etc – are nothing like a U.S. insurance company. The main reason people usually propose the German (or French, etc.) model for the U.S. is that they believe it will be more ‘politically feasible’ than single payer because we could avoid a showdown with the private insurance industry. But that’s false. Aetna has nothing in common with a sickness fund: Sickness funds are, after all, non-profit, and so tightly regulated that they don’t set either fees or premiums. U.S. insurers would resist being turned into ‘sickness funds’ exactly as much as they would fight single payer. So, there’s no political advantage. Plus, having multiple payers (even non-profit ones) does increase administrative overhead, and decrease ability to control costs.”

The mission of the New America Foundation is to bring new, innovative thinking into the public discourse. It is ironic that they are promoting the oldest approach to universal coverage, sickness funds, while rejecting the newest and most efficient form of universal coverage, single payer.

They use the rhetoric of shared responsibility, as if this were a new concept. Of course, all universal systems depend on shared responsibility. A single payer system partners a public funding system with a private health
care delivery system.

If they believe that highly regulated and controlled sickness funds administered by multiple insurers is a great idea, then maybe they might be interested in a newer innovation of that concept. Establishing a single, universal sickness fund, administered regionally by a single public entity, would improve the efficiency and efficacy of the sickness fund concept.

Does someone want to tell Steven Hill and his colleagues at the New America Foundation that the take-home lesson is that we don’t have to settle for the ancient model of multiple private insurers and sickness funds, when we have
the opportunity to adopt an improved universal system by applying modern single payer innovations?

Note: There will be no Quote of the Day messages during the remainder of July. They will resume in August.

Stretching the brittle Medicaid dollar

Can States Stretch The Medicaid Dollar Without Passing The Buck? Lessons From Utah
By Samantha Artiga, David Rousseau, Barbara Lyons, Stephen Smith and Daniel S. Gaylin
Health Affairs
March/April 2006

In some states, Medicaid restructuring has already begun through waivers. In 2002 Utah became the first state to use a new waiver approach, under which the state financed an expansion in primary care coverage, called the Primary Care Network (PCN), with “savings” obtained from benefit reductions and cost-sharing increases for parents already covered by Medicaid.

Utah financed an expansion in primary care coverage for low-income adults by limiting benefits and raising cost sharing for very poor parents receiving Temporary Assistance for Needy Families (TANF) (with incomes below 54 percent of the federal poverty level, or $8,964 per year for a family of three in 2006), parents who recently left TANF because of employment, and parents with high medical expenses who “spent down” to qualify for Medicaid.

These reductions offset the costs of a coverage expansion to uninsured parents and other adults with incomes below 150 percent of poverty ($24,900 per year for a family of three in 2006) who were not previously eligible for Medicaid. These people became eligible for the new PCN program offering only primary care coverage, with no coverage for hospital (other than ER), specialty, or mental health care.

Although the PCN enrollees appeared to be benefiting from their coverage, their major health care needs and limited resources raise concerns that a package covering solely primary care falls short of providing adequate insurance. More than three-quarters of enrollees said they needed health services that were beyond the scope of their coverage. Further, compared with the Non-Traditional Medicaid enrollees, who have broader coverage and more limited cost sharing, they were more likely to report missing or postponing getting needed medical care because of cost or lack of coverage. When compared with national survey findings for adults with incomes below 150 percent of poverty, PCN enrollees’ reports of missing or delaying care were much higher than national rates for adults covered by Medicaid (36 percent versus 12 percent) and were closer to national rates for uninsured adults with incomes below 150 percent of poverty (29 percent).

http://content.healthaffairs.org/cgi/content/abstract/25/2/532

And…

Arkansas Set to Undertake a Novel Effort in Health Care
By Robert Pear
The New York Times
March 7, 2006

The Bush administration is poised to approve an innovative health insurance program, proposed by Arkansas, for 80,000 low-income uninsured people in the state, officials said Monday.

Arkansas will carry out the program, to be announced on Tuesday, under a waiver allowing the state to receive federal Medicaid money for coverage that does not meet the usual Medicaid standards for eligibility and benefits.

The employer-based program is novel in two ways. The benefit package is extremely limited, much more austere than Medicaid’s. In addition, if an employer wants to participate, it must guarantee that all its employees, regardless of income or other factors, will be covered.

People who sign up for the program will receive a basic benefit package covering six doctor visits a year, seven days of inpatient hospital care a year, two outpatient hospital procedures or emergency room visits a year and two prescription drugs a month.

Federal officials said the Arkansas program could be a model for other states that want to expand coverage without substantially increasing costs.

http://www.nytimes.com/2006/03/07/politics/07health.html?_r=1&oref=slogin

Comment: By Don McCanne, M.D.

Michael Leavitt, when he was governor of Utah, introduced innovative restructuring through the Medicaid waiver process that produced the plan described in the Health Affairs article above. The results of this study demonstrate that Leavitt’s innovative program resulted in beneficiaries missing or delaying care at rates comparable to the uninsured.

Now, as secretary of health and human services, Michael Leavitt is poised to approve the Medicaid waiver for Arkansas’ innovative program. What is particularly disconcerting is that this new innovation not only replicates to some extent the flawed plan adopted by Utah for low-income individuals, but this plan also establishes the principle that employees of small businesses are entitled only to the same, almost worthless coverage.

Unfortunately, our nation’s leaders have defined the problem as a need to reduce the numbers of uninsured, when the real problem is that we need to reduce the numbers who cannot afford access to health care. To expand insurance coverage without spending more, consumer-directed innovations are being used to shift more of the costs to patients. These Medicaid innovations establish an inverse relationship between income levels and the amount of cost shifted to the patients. Very low income patients are having almost all of the costs shifted to them.

In 2000, the World Health Organization ranked the United States 54th in the fairness of funding of our health care system. At least our administration will be able to show us an upward sloping curve as they graph out the growth of that number. Or maybe they’re looking at the inverse as they try to become # 1, the most inequitable system of all nations.

The health care crisis and what to do about it

The Health Care Crisis and What to Do About It
By Paul Krugman, Robin Wells
The New York Review of Books
March 23, 2006

The good news is that we know more about the economics of health care than we did when Clinton tried and failed to remake the system. There’s now a large body of evidence on what works and what doesn’t work in health care, and it’s not hard to see how to make dramatic improvements in US practice.

The bad news is that Washington currently seems incapable of accepting what the evidence on health care says.

1. Is health care spending a problem?

2. The unraveling of employer-based insurance

3. Medicaid and Medicare

4. The “consumer-directed” diversion

5. Single-payer and beyond

6. Beyond reform: How much health care should we have?

7. Can we fix health care?

A mere shift of power from Republicans to Democrats would not, in itself, be enough to give us sensible health care reform. Even liberal economists and scholars at progressive think tanks tend to shy away from proposing a straightforward system of national health insurance. Instead, they propose fairly complex compromise plans. But the main reason for not proposing single-payer is political fear: reformers believe that private insurers are too powerful to cut out of the loop, and that a single-payer plan would be too easily demonized by business and political propagandists as “big government.”

These are the same political calculations that led Bill Clinton to reject a single-payer system in 1993, even though his advisers believed that a single-payer system would be the least expensive way to provide universal coverage. Instead, he proposed a complex plan designed to preserve a role for private health insurers. But the plan backfired. The insurers opposed it anyway, most famously with their “Harry and Louise” ads.

We believe that the compromise plans being proposed by the cautious reformers would run into the same political problems, and that it would be politically smarter as well as economically superior to go for broke: to propose a straightforward single-payer system, and try to sell voters on the huge advantages such a system would bring. But this would mean taking on the drug and insurance companies rather than trying to co-opt them, and even progressive policy wonks, let alone Democratic politicians, still seem too timid to do that.

So what will really happen to American health care? Many people in this field believe that in the end America will end up with national health insurance, and perhaps with a lot of direct government provision of health care, simply because nothing else works. But things may have to get much worse before reality can break through the combination of powerful interest groups and free-market ideology.

http://www.nybooks.com/articles/18802

Comment: By Don McCanne, M.D.

You likely do not have the time right now to read this very long article. The sections are listed above simply to demonstrate that it really does address the health care crisis and what to do about it, as promised in the title. Save this for your next break.

Do not be deterred by the fact that this is a book review, actually a review of three books. It is a stand-alone article on our health care crisis, not constrained by the subject matter of the books reviewed.

You should encourage others who are concerned about our health care system to take the time read this article. You can assure them that most authors would have required an entire book to communicate the messages that Krugman and Wells have presented here in a single article. In this day of information overload, you’ll rarely find a bargain like this: a lucid perspective of the basics of our health care crisis with a very modest commitment of time.

Tell everyone to read it.

Remedy for ailing system sought

Forums to examine possible solutions to health care cost crisis
By Matt Pacenza
Times Union, Albany, New York
Monday, March 6, 2006

ALBANY — The bill gets bigger every day. By 2015, one out of every five dollars spent in America will pay for health care — $4 trillion, according to a recent study.

There has to be a better system than the current U.S. hodgepodge of private and public insurance, which is unnecessarily costly yet also leaves millions with inadequate care, according to a diverse group of activists and business people that has come together in recent years to seek an alternative.

Four forums to debate transforming the health care system will be held over the coming month at WAMC’s Linda Norris Auditorium at 318 Central Ave. The lunchtime symposiums, open to the public, won’t just bring together those who back universal health care.

“People are participating from different points of view,” said Dr. Paul Sorum, chairman of the Capital District chapter of Physicians for a National Health Program and event organizer. “We expect a lot of interesting and passionate exchanges between them and members of the audience.”

The first session — from noon to 2 p.m. on Tuesday — includes Dr. Oliver Fein, a Cornell medical school dean who backs universal health care, Dr. Jeremy Lazarus from the American Medical Association, which supports free-market approaches, and the chief of the Capital District Physicians Health Plan, Dr. William Cromie. Rounding out the panel — called “What is wrong with the current system? Would ‘Medicare for All’ remedy these deficiencies?’ ” — is Albany Med’s well-known bioethicist, Glen McGee.

Each forum will be moderated by WAMC President Alan Chartock and edited for broadcast.

The time is ripe for an in-depth debate on health care, said Sorum, who is also a professor of internal medicine and pediatrics at Albany Medical College. He listed the issues grabbing headlines across the country: “The rising cost; the number of people who don’t have health insurance; the screams of business people who can’t afford to provide insurance, even if they would like to; the rising cost of Medicaid, and its burden on county taxpayers.”

Anyone interested in attending the forums is asked to pre-register by e-mailing pnhpalbany@verizon.net or by calling (518) 391-2508. The other three panels will be held on:

March 27, 1 to 3 p.m. “What lessons can we learn from other countries?”

April 10, noon to 2 p.m. “What would an expanded Medicare for all look like?”

April 24, noon to 2 p.m. “Can we institute Medicare for all in a single state, namely New York?”

The Uninsured Patient

By Baldeep Singh, MD, and Rachel Golden, PhD
Commentary
The American Journal of Medicine
February 2006

Despite recent attempts by federal programs to increase access to medical care for uninsured persons, the number
of Americans without insurance has increased since 1994 by an average of one million per year, and 2.4 million in
2002. By 2002, 43 million Americans were uninsured, comprising 17.3% of the nonelderly population (Kaiser
Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000). Even this number may
underestimate the extent of the problem; recent data from the Kaiser Commission found that approximately 30% of
Americans, more than 70 million people, lacked health care for at least 1 month over a 3-year period (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).1

Many Americans have lost coverage throughout the past decade because of the increasing cost of health insurance, which has resulted in larger costs to individuals for premiums and co-pays, and decreased availability of employer-based health insurance.1 For example, in a study by Cooper et al.2 in 1997, two-thirds of those without employer-based insurance cited the high cost of health insurance plans as the main reason they were not covered. Similarly, despite the robust economy of the late 1990s, an increasing percentage of companies cited the high cost of health care plans as the main reason they were dropping medical coverage for or shifting costs to their employees (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).

During the past decade, the U.S. Congress has passed regulatory reforms and enacted new programs in an attempt to increase opportunities for Americans to obtain and maintain health insurance coverage. Two incremental reforms in private health insurance regulation, the Consolidated Omnibus Reconciliation Act and the Health Insurance Portability and Accountability Act, were legislated to increase opportunities for Americans to maintain their insurance coverage, but these regulations have not stopped the numbers of uninsured Americans from continuing to increase. In the public sector, large increases in Medicaid eligibility over the past two decades, as well as the enactment of the State Children痴 Health Insurance Program in 1997, were designed to increase eligibility for public programs, but have also failed to decrease the number of uninsured patients in the United States (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).

The uninsured tend to be young, working poor, minority families. They tend to have worse health, and when they do become ill, have worse outcomes. This article identifies important demographic trends among the uninsured and explores the barriers they face in getting and keeping health care coverage. More importantly, these barriers significantly affect health outcomes and reveal a growing divide in health care access that is affecting the nation痴 health as a whole.

COVERAGE BY TYPE OF HEALTH INSURANCE

In 2002, the uninsured represented 17.3% of the nonelderly, American population. Because almost everyone 65 years of age or more has Medicare, children and adults aged less than 65 years of age make up the majority of the uninsured. Among insured Americans aged less than 65 years of age, employment-based health insurance covers 63.3%, Medicaid covers 12%, and Medicare covers 2%.1

There is a common misperception that the Medicaid program provides health coverage for all low-income Americans, when, in fact, its policy toward low-income adults is quite restrictive. Although the program covers many low-income children, there are only a few eligibility pathways for adults, aside from being significantly disabled or pregnant預nd those that do exist are primarily limited to single parents with very low incomes. Parents working full-time at the minimum wage, for example, are not eligible for Medicaid in the majority of states (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000). Even if one does qualify for Medicaid, strict eligibility makes coverage difficult to keep. At the end of any given year, two-thirds of those who were insured by Medicaid will have lost their coverage.3 The federal welfare reforms enacted in 1996 have affected the Medicaid enrollment process and have been associated with decreases in Medicaid coverage. In addition, these reforms have served to increase the number of uninsured because those leaving welfare move into the workforce to take low-wage positions for which health benefits are less likely to be offered or affordable.

For individuals who are self-employed, work in small companies, or have opted out of their employer痴 health insurance plans, the alternative is private, nongroup insurance. However, private, nongroup insurance covers only 5.3% of the population. The major reason there are not more enrollees is the relatively high cost of such plans compared to family income. For example, the maximum income of families at 200% of the 2004 federal poverty level was $37 700 for a family of 4, whereas the full premium for this family averaged more than $7000 per year. Thus for low-income families, comprising twothirds of the uninsured, premiums remain out of reach.3 Furthermore, workers who have health insurance typically pay one-quarter to one-third of the total cost of family coverage premiums.

COVERAGE BY AGE

Young adults, 19 to 34 years of age, comprise just a quarter of the nonelderly population, but represent 40% of the uninsured.1 Young adults are at higher risk of being uninsured because they are less likely to be married and therefore have only themselves as a link to job-based health benefits. They also earn lower incomes on average and are usually not eligible for Medicaid. Three million young adults are uninsured because they decline to purchase available health insurance because of high premiums and co-pays. But, 11 million young workers are uninsured because their employers do not offer health insurance, and they cannot afford to purchase coverage elsewhere.2 This latter group comprised 75% of the growth in the number of uninsured in recent years (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).

More than half of the uninsured come from families with children, and 1 in 5 of the uninsured is a child. Thanks to recent expansions in Medicaid and the State Children痴 Health Insurance Program, the percentage of children who are uninsured has not increased for the last 3 years. Nevertheless, 10 million children less than 18 years of age in the United States do not have medical insurance even though it is estimated that 95% of them are eligible for public insurance.7 In general, eligible children are more likely to be enrolled in public programs if the rest of the family has coverage. In particular, the insurance status of parents seems to affect whether their children receive care, as well as how much, even if the children have coverage (Kaiser Family Foundation/Lehrer Survey About the Uninsured, unpublished data, February 2000).

COVERAGE BY INCOME

In 2002, 27% of the uninsured were from families with incomes below the Federal Poverty Level ($14 348 for a family of 3), 39% had family incomes between 100% and 200% of the Federal Poverty Level, and the remaining 36% of the uninsured were from families with higher incomes. This third group represents the fastest growing segment of the uninsured over the past 3 years.1 Nonetheless, approximately one-third of all members of families living at or below 200% of the Federal Poverty Level, are uninsured, placing an undue burden on this segment of the population as a whole.

Workers with lower incomes are offered employmentbased insurance plans much less often than those with middle to upper incomes. Only 55% of workers whose hourly rate is less than $7 are offered health insurance through their own or a family member痴 job, compared with 96% of workers whose hourly rate is more than $15. 9

COVERAGE BY EMPLOYMENT STATUS

It is a myth that most of the uninsured are unemployed. In fact, 80% of uninsured children and adults less than 65 years of age live in working families. Even members of families with two full-time workers have a 1 in 10 chance of being uninsured.3 Only 19% of the uninsured live in families with just part-time workers or no member working outside the home.1 Nonetheless, members of families without wage earners are much more likely to be uninsured than members of families with wage earners.

Low-wage workers have born the brunt of higher premiums and cost sharing. Thirty-two percent of all low-wage families are not offered health insurance by their employers.10 In fact, rates of employer-sponsored coverage among low-wage workers (making $7/hour) decreased between 1987 and 2000, whereas rates of coverage for high-wage workers actually increased. In fact, 96% of higher-wage workers were offered employerrelated health benefits, and 90% were insured by an employer-sponsored plan.

The highest rate of uninsured workers is found among employees in small firms (25 workers) or self-employed. Thirty-five percent of workers in small firms are uninsured, compared with only 13% in large firms of 100 employees or more.1 However, regardless of firm size, the chances of having job-based coverage are less for those with lower incomes, even for those employees who are full-time.

Blue-collar workers constitute 63% of the work force in the United States, but they represent 81% of the uninsured. This is because they are less likely than white-collar workers to be offered health insurance as a benefit.1

When employers do offer insurance plans, the cost of these programs places a disproportionate burden on low-wage workers. The expense of insurance premiums paid by employees tops the list of reasons why uninsured workers decline to take employment-based insurance when it is offered.11 In 1995, the proportion of workers who paid more than 10% of their family income for health care expenditures increased to 33%.12

COVERAGE BY RACE, ETHNICITY, AND GENDER

Although racial minorities formed one-third of the nonelderly population, they comprised more than half of the uninsured. More than one-third of Latinos are uninsured, and a quarter of both African Americans and Native Americans have no health coverage. African Americans are twice as likely and Latinos are 3 times as likely as non-Hispanic whites to be uninsured.13 The differences in health coverage across racial and ethnic groups are only partially explained by differences in income. Two other factors are evident here. Minority groups are less likely, on average, than non-Hispanic whites to hold jobs that offer health insurance, and they are less able to afford workplace insurance coverage when it is available.

Gender disparities in health coverage are also evident. Adult men are more likely than women to be uninsured. Conversely, women have lower rates of employmentbased coverage. Women are more likely to obtain insurance policies through individual and public programs, usually when they are lower-income and pregnant or with young children. Women with public insurance status, however, tend to have greater instability in their health coverage, providing more opportunities for gaps in coverage.14

COVERAGE BY COUNTRY OF ORIGIN AND IMMIGRATION STATUS

US citizens make up the majority of the uninsured. Although public opinion polls suggest that Americans think most of the uninsured are noncitizens, in fact, noncitizens comprise only 20% of the total uninsured patients. However, this group is at the highest risk (45%) of being uninsured, and immigrant uninsured rates decline with increasing length of residency in the United States.3,15

Recent immigrants are 3 times as likely as members of the general population to be uninsured, but they only comprise 6% of the total uninsured. Disparities in the uninsured rates between immigrants and native-born US residents reflect the lower rates of employer-based coverage among immigrants, as well as their likelihood of employment in lower-waged positions.16 Compounding the problem for immigrants, since 1996, federal welfare and immigration reform legislation have banned legal immigrants arriving after 1996 from eligibility for Medicaid, The State Children痴 Health Insurance Program, and other federal means-tested benefits programs. Except for emergency care, immigrants are not eligible for coverage through these programs during their first 5 years in the United States.17

COVERAGE BY GEOGRAPHIC LOCATION

More than 20% of the nonelderly uninsured population reside in the southwest and south central states, where poverty rates are higher and rates of employer-sponsored coverage are lower than the national average. The amount a state provides in assistance to the uninsured depends on the proportion of families with low incomes, the structure of the state痴 unemployment benefits, and the inclusiveness of the state痴 Medicaid programs. A threefold difference exists between the states with the lowest (9%) and highest (27%) rates of uninsured. Reflecting the predominantly urban locations of the general population, most uninsured persons live in urban areas, although rural and urban residents are equally likely to be uninsured.15

DOES COVERAGE AFFECT MEDICAL OUTCOMES?

There is an association among health insurance coverage, access to health care, and patient outcomes. Although 57% of the public reported they believe that those without health insurance are able to get the care they need, one survey found that the uninsured were less than half as likely as those with insurance to receive medical care for a serious medical condition, as judged by physicians.18

The most important prerequisite for access to care is health insurance coverage. Without it, most people cannot afford medical care. They are more likely to postpone or go without necessary treatment for fear of high medical bills.19 In fact, uninsured adults are at least four times as likely as the insured to report delaying or foregoing needed health services.

Growing evidence from large observational studies reveals the staggering effects of insurance status on general health outcomes. The uninsured poor, for example, are more likely to delay hospitalization compared with those with private health insurance, and when in the hospital, uninsured patients stay longer and experience higher death rates. In addition, hospitalized uninsured patients are 2.3 times more likely than those with insurance to have adverse iatrogenic events.20,21 Uninsured patients are twice as likely to die over 15 years compared with insured patients (18.4% vs 9.6%); even after adjusting for major health risk factors, mortality remains 25% higher among the uninsured.22

The effects of poor access to care for the uninsured are particularly striking for diseases which require early detection. The uninsured receive fewer preventive services such as blood pressure checks, mammograms, and screening for colorectal cancer.2 For example, the loss of Medicaid coverage has been associated with a 10-point increase in diastolic blood pressure and a 15% increase in the hemoglobin A1C in diabetic patients. This has translated into a higher probability of death over 6 months.21 In addition, because regular preventive care is not received, the uninsured are more likely to be diagnosed at advanced stages of cancer. Greater than 40% of uninsured women are more likely to be diagnosed with latestage breast cancer, and 40% to 50% are more likely to
die of breast cancer, compared with insured women, depending on their age.23

In the case of acute care, outcomes are consistently worse for uninsured patients. Among patients with appendicitis, for example, uninsured individuals were 1.5 times more likely than insured patients to present with an
appediceal rupture.24

CONCLUSION

The problem of the uninsured in the United States is rapidly becoming a crisis, affecting a broader crosssection of society with each passing year. Growth in the numbers of uninsured Americans has continued annually for over the past decade, and currently more than 17% of the nonelderly population are uninsured. The poor and members of certain minority groups have historically been excluded by a system of voluntary health insurance in the United States. However, contrary to public perception, most Americans without health insurance today are members of working families and are U.S. citizens. The crisis of the uninsured has increasingly become a problem that reaches all racial, ethnic, and socioeconomic groups, and across a wide spectrum of occupations. Despite recent attempts to improve pediatric insurance coverage, children remain 20% of the total uninsured population.

The uninsured are battling both the decreasing affordability and availability of private health insurance, as well as the increasing restrictions on public health insurance programs. Despite an improved economy, obtaining low-cost health care when needed is becoming more difficult for the uninsured. Fewer employers cover their workers because of the increasing cost of health care, and fewer people can afford to pay. The high cost of private insurance plans themselves clearly affects access to medical services in that fewer people can afford health insurance. In addition, the increasing level of out-of-pocket costs for premiums and co-pays reduces usage of health care services.25,26 Governmental reforms to increase private and public health insurance have made little impact, and in some cases have made the problem worse. Thus, the gap between the increasing cost of health care and the reduced purchasing power of those trying to access health care seems to be the biggest factor in this national crisis.

Furthermore, the uninsured are more likely to have poorer health outcomes than those with health insurance. The high cost of care causes many uninsured people to postpone or forego necessary treatment. As a group, the uninsured are having their diseases detected later, and their morbidity and mortality are higher.

Whether or not one has health insurance affects job decisions, financial security, access to care, and health status. But lack of insurance and gaps in coverage affect all of society. When an uninsured person goes to a public hospital or clinic, an emergency department, or a private physician for care and cannot pay the full cost, some of the bill is passed on to those who do pay, through higher insurance premiums and in the form of taxes supporting our public medical insurance programs. We all pay for having a large and growing uninsured population.

Americans have boasted for years that we have the best health care in the world, but if this is true, it is the case only for those with health insurance. In fact, the clear relationship between insurance status and health outcomes should be considered a national emergency. If access to medical care and health care coverage correlates with improved clinical outcomes, where is the cry from the medical profession to increase both of these? If doctors are entrusted with improving the health care of our patients, we must be at the forefront of moving legislation toward increasing the coverage of all our citizens, thereby increasing the overall health of our nation.4-6,8

Baldeep Singh, MD
UCLA Department of General Internal Medicine
Los Angeles, Calif.

Rachel Golden, DrPh
South Los Angeles Health Projects
Los Angeles Biomedical Research
Institute at Harbor-UCLA
Medical Center, Calif.

References
1. Kaiser Commission on Medicaid and the Uninsured; 2002.
2. Bennefield R. Dynamic of Economic Well-Being: Health Insurance, 1993 to 1995. Who Loses Coverage and for How Long? Census Bureau Current Population Reports. Household Economic Studies, 70-64.
3. Cooper PF, Schone BS. More offers, fewer takers for employment based health insurance: 1987 and 1996. Health Aff (Milwood) 1997; 16(6):142-149.
4. Fronstin P. The Economic Cost of the Uninsured: Implications for Business and Government. Employee Benefit Research Institute. 5. Kellerman A. Health policy and clinical practice/health policy report. Ann Emerg Med 2002;40:644-647.
6. Gabel J, et al. The Financial Burden of Self Paid Health Insurance on the Poor and Near Poor. 1998.
7. Broaddus M, et al. Nearly 95 Percent of Low-Income Uninsured Children Now Are Eligible for Medicaid or S-CHIP. Center on Budget and Policy Priorities; 2000.
8. Hanson K. Is insurance for children enough? The link between parents・and children痴 health care revisited. Inquiry 1998;35(3): 294-302.
9. Cooper PF, Schone BS. More offers, fewer takers for employment based health insurance: 1987 and 1996. Health Aff (Milwood) 1997; 16(6):142-149.
10. Custer ??, et al. The Changing Sources of Health Insurance. Health Association of America; 2000.
11. Hoffman C, et al. Uninsured in America: A Chart Book. The Kaiser Foundation; 2000.
12. Kronick R, Gilmer T. Explaining the decline in health insurance coverage, 1979-1995. Health Aff (Milwood). 1999;18(2):30-47.
13. Mills R. Health Insurance Coverage, 1999. Current Population Reports. 60-211. 166.e4 The American Journal of Medicine, Vol 119, No 2, February 2006
14. Fronstin P. The Economic Cost of the Uninsured: Implications for Business and Government. Employee Benefit Research Institute.
15. Coverage Matters. Insurance and Health Care. Institute of Medicine; 2001.
16. Carrasquillo O, Carrasquillo AI, Shea S. Health insurance coverage of immigrants living in the united states: differences by citizenship status and country of origin. Am J Public Health 2000;90(6):917-923.
17. Rosenbaum S, et al. Medicaid Eligibility and Citizenship Status: Policy Implications for Immigrant Populations. Policy Brief no. 2201. Kaiser Commission on Medicaid and the Uninsured; 2001.
18. Blendon RJ, Young JT, DesRoches CM. The uninsured, the working uninsured and the public. Health Aff (Milwood) 1999;18(6):203-211.
19. Baker D, et al. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency room. JAMA 271(24):1909-1912.
20. Levit KR, Freeland MS, Waldo DR. Health spending and ability to pay, business, individuals, and government. Health Care Financing Rev 1989;10(3):1-11.
21. Berghold LA. Purchasing Power in Health. Piscataway, NJ: Rutgers University Press; 1990.
22. DiCarlo S, Gabel J. Conventional health insurance: a decade later. Health Care Financing Rev 1989;10(3):77-89.
23. Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med 1993;329(5):326-340.
24. Braveman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med 1994;331(7):444-449.
25. Zweifel P, et al. Consumer incentives in health care. Handbook of Health Economics. 2000:410-459.
26. Wielawski I. Gouging the medically uninsured. A tale of two bills. Health Aff (Milwood) 2000;19(5):180-185.

Our health care system is inefficient, wasteful

Maine

Who among us cannot be ashamed that more than 45 million Americans lack health insurance and millions more have inadequate coverage? How do we spend twice as much as anyone else while being the only developed nation not to provide universal health coverage for its people?

The high cost of private insurance billing is one part of the problem. A recent study published in Health Affairs (www.pnhp.org/Kahn/kahn_galley.pdf) shows that 1 in 5 health care dollars goes to billing and paperwork. A 2003 Harvard study pegged these costs at 31 percent of U.S. health spending — about $400 billion — vs. 17 percent in Canada.

It is no surprise that our fragmented health care financing system is very inefficient and wasteful. Dozens of insurance companies have their own departments for enrollment, exclusions, referrals, billing, sales and marketing. Add to this massive duplication of effort the cost of huge salaries to CEOs, and shareholder profits generated by minimizing payments for patient care services.

The money squandered is more than enough to cover the uninsured and to eliminate exclusions, co-payments and deductibles that often bankrupt even insured families in the face of serious illness.

Only single payer national health insurance can squeeze the bureaucratic waste out of health care and use the savings to give patients affordable, high-quality and comprehensive care without waits.

As a member of Physicians for a National Health Program, I urge everyone to learn more about how to deal with our health care crisis by visiting www.healthcare-now.org.

John Benziger
South China

thebenzigers@hotmail.com

AHPs for the Blues

Sen. Enzi To Introduce Compromise Legislation on Association Health Plans
Kaiser Daily Health Policy Report
March 3, 2006

Senate Health, Education, Labor and Pensions Committee Chair Michael Enzi (R-Wyo.) early next week plans to introduce a bill (S 1955) that would allow association health plans to form under certain conditions, and he has scheduled a March 8 markup for the proposal, CongressDaily reports (CongressDaily, 3/3). Like two other pending bills, Enzi’s proposal would allow small businesses and trade associations to join together to offer group health coverage on a statewide or nationwide basis. However, Enzi’s bill differs from pending House (HR 525) and Senate (S 406) legislation in that it would require AHPs to cover any benefits mandated by at least 45 states. To address further the concerns of opponents who say the plans would impair state-mandated consumer protections, Enzi’s bill would leave supervision of the plans with state officials rather than the Department of Labor. In addition, while the bill “would permit business and trade associations to pool their members independently, they would not be allowed to establish self-insured plans, but would rather have to provide benefits through a fully-funded plan,” CQ HealthBeat reports. Enzi said, “Working with a diverse group of senators and business groups representing small business, we’ve bridged the gap between small business proponents of traditional AHPs and state-based interests worried about the prospects of dramatic regulatory changes in health insurance markets.” Mary Nell Lehnhard, senior vice president of the Blue Cross Blue Shield Association, a group that has opposed other AHP proposals, said, “I feel all of our concerns have been listened to. The process has been amazing.”

http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=35779&dr_cat=3

S. 1955:
http://thomas.loc.gov/cgi-bin/bdquery/z?d109:s.01955:

And…

January 21, 2006
President’s Radio Address
The White House

Congress also needs to pass Association Health Plans, which allow small businesses across the country to join together and pool risk so they can buy insurance at the same discounts big companies get.

http://www.whitehouse.gov/news/releases/2006/01/
20060121.html

Comment: By Don McCanne, M.D.

Proposals for Association Health Plans (AHPs) have been criticized partly because they allow circumvention of state mandated benefits. The savings for small businesses would not come from group discounts, but rather from being able to purchase stripped down plans with very low premiums. Such plans would fall far short of the protection that their employees need. Also they would allow employers who currently provide coverage to drop their plans in favor of these cheap alternatives.

Sen. Enzi’s proposal pretends to address this issue by requiring that benefits mandated by at least 45 states be covered. If only 6 states fail to mandate any given benefit, then it would not be a requirement of the AHPs. Although I haven’t seen any survey, it is improbable that there is any state mandate that would end up being a required benefit for AHPs.

Insurers have not been supportive since they could be left out if the AHPs established their own self-insured pools. Small businesses are potentially a very large market for insurers. Sen. Enzi’s new version pleases the insurers since it would require that benefits be provided through fully-funded plans.

The BlueCross BlueShield Association management finds it amazing that their concerns were listened to. S 1995 will protect and enhance their market for their highly profitable, stripped down plans.

So the President and his colleagues in Congress are addressing the concerns of his friends in the insurance industry.

But, Mr. Bush… What about the patients?

Recourse Grows Slim for Immigrants Who Fall Ill

By Nina Bernstein
The New York Times
March 3, 2006

When Ming Qiang Zhao felt ill last summer, he lay awake nights in the room he shared with other Chinese restaurant workers in Brooklyn. Though he had worked in New York for years, he had no doctor to call, no English to describe his growing uneasiness.

Mr. Zhao, 50, had been successfully treated for nasal cancer in 2000 at Bellevue Hospital in Manhattan, which has served the immigrant poor since its founding in 1736. But the rules there had changed, and knowing that he would be asked for payment and that security guards would demand an ID, he had concluded that he could not go back.

So Mr. Zhao went to an unlicensed healer in Manhattan’s Chinatown and came away with three bags of unlabeled white pills.

A week later, his roommates, fellow illegal immigrants from Fujian Province in China, heard him running to and from the toilet all night. In the street the next day, July 6, he collapsed.

Immigrants have long been on the fringes of medical care. But in the last decade, and especially since the terrorist attacks of Sept. 11, 2001, steps to include them have faltered in a political climate increasingly hostile to those who face barriers of language, cost and fear of penalties like deportation, say immigrant health experts, providers and patients. More and more immigrants are delaying care or retreating into a parallel universe of bootleg remedies and unlicensed practitioners.

Last year, about 80 bills in 20 states sought to cut noncitizens’ access to health care or other services, or to require benefit agencies to tell the authorities about applicants with immigration violations. Arizona voters approved such a requirement in 2004 with Proposition 200. Virginia has barred adults without proof of citizenship or lawful presence from state and local benefits. Maryland’s governor excluded lawful immigrant children and pregnant women from a state medical program for which they had been eligible.

Most proposed measures were not adopted, but new versions are expected. Ballot initiatives modeled on Arizona’s Proposition 200 are circulating in California and Colorado. And in December, the United States House of Representatives passed a sweeping bill that would make “unlawful presence” in this country a felony and redefine “criminal alien smuggling” to include helping any immigrant without legal status.

“We’ve seen a real rise in anti-immigration measures across the country,” said Tanya Broder, a public benefits lawyer in Oakland, Calif., for the National Immigration Law Center, “and it’s engendered confusion and fear that prevent immigrant families from getting the care they need.”

Some who had been drawn into medical treatment by outreach efforts have retreated, like Mr. Zhao, fearing the harder line toward immigrants, especially those without money or proper papers. Even legal immigrants and parents of children with legal status are more skittish about their health care, scared that medical bills and public medical insurance can hurt their chances for citizenship, bar relatives from coming to the United States or break up their families.

“I heard that if you go to the emergency room or go to the doctor, they were going to deport you,” said Alejandra, a mother from Colombia living in Queens, referring to a rule proposed in 2004 by the Centers for Medicare and Medicaid Services that would have made hospitals report the immigration status of emergency-room patients in exchange for more federal money. “So then my four children are going to be without me because I don’t have documents here.”

The proposal did not pass, but like many of the proposed rules immigrants hear about on television or from neighbors, its chilling effects lasted.

Restrictive bills are part of what supporters describe as a movement to end tolerance for the country’s estimated 11 million illegal residents.

“It’s certainly an effort to make them go back,” said Dan Stein, president of the Federation for American Immigration Reform, a group calling for fewer immigrants and stricter enforcement of immigration laws. “It will never be acceptable for people to break our laws and then expect taxpayers to provide health care.”

Almost by definition, the most fearful immigrants are the least likely to talk. The Colombian mother in Queens, however, was among 75 immigrant parents, both legal and illegal, who were interviewed in depth by researchers from the New York Academy of Medicine for a study to be released later this year, with the guarantee that their real names would be withheld.

What emerges from the transcripts, and from dozens of other interviews conducted by The New York Times with patients, health-care providers and experts on immigration, is a picture not only of heightened anxiety but also of immigrants who are primed to flee rather than fight for help from a system that even the native-born often find baffling and rude.

For Nadege, pregnant and in pain when she sought treatment at Queens Hospital Center, a public hospital, the defining moment was a snub by a fellow Haitian who had been summoned to interpret. “She said to me, ‘Don’t come here saying that you have a bellyache: no one is going to stay with you the entire day,’ ” Nadege recalled.

“I cried,” she said. “I picked up my belongings and left. Even if I was dying that day, I wouldn’t go back.”

Lard and Vodka, Not Doctors

No one is suggesting that hospitals and clinics are seeing a decline in immigrant patients. On the contrary, as a decade of record immigration continues at an estimated annual clip of 1.2 million newcomers, the number of patients who speak little or no English is growing everywhere. And some hospitals and clinics are trying harder than ever to at least meet language needs.

But even in New York, a gateway of immigration, a national climate that makes immigrant patients more timid also emboldens some front-line workers to bar the way.

“If you have one renegade public-benefits worker who thinks they should be discouraging access because they believe it’s a drain on taxes, the word on the street is it’s too much of a hassle to apply,” said Adam Gurvitch, director of health advocacy for the New York Immigration Coalition, an umbrella group for more than 150 immigrant organizations.

Problems getting insurance sometimes lead to risky decisions about children’s health care. A legal immigrant from Russia, Oksana, confessed to academy researchers that she had delayed her daughter’s vaccinations for months, keeping her out of school until she could borrow $300 to pay for them. Melosa, of Mexico, had so many problems with state-subsidized insurance that when her severely asthmatic son ran a high fever she resorted to rubs of pig lard and carbonate, instead of taking him to a doctor.

Vera, a Brooklyn mother from Belarus, used vodka rubs and borrowed medications when her daughter was delirious with fever from the flu. “We couldn’t go to the doctor without medical insurance,” she said.

In the end, immigrants often return to mainstream care in dire need, only to have their chaotic medical histories compounded by a beleaguered system whose costliest medical technology is no substitute for timely treatment. In Mr. Zhao’s case, an ambulance took him, unconscious, to a bankrupt hospital system where his life hung in the balance for weeks, and where one of his roommates, a 19-year-old waiter with uneven English, served as the interpreter.

“No money, no ID, no good English,” said the waiter, Hong Chung. “What you going to do? Nobody pay attention to us.”

Mr. Zhao was in a coma when his brother, Ming Tong, 49, and Fujianese friends came to the hospital, clutching the unlabeled pills, which had been described as herb-based remedies for high blood sugar, high blood pressure and insomnia.

Mr. Chung remembers pleading, “If you find out the name of the ingredients, maybe he won’t have to die.” But he said doctors told him that the hospital was unable to do such an analysis. The hospital, St. Mary’s in Brooklyn, was scheduled to close after more than a century serving the immigrant poor. St. John’s in Queens, where Mr. Zhao was transferred for more tests 12 days later, was up for sale. Their parent organization, St. Vincent’s Catholic Medical Centers, the largest Roman Catholic hospital system in New York State, had just filed for bankruptcy protection.

At struggling hospitals, interpretation can seem like a luxury, despite longstanding federal and state laws requiring equal language access and studies showing that it cuts cost by improving quality. Few hospitals have laboratories capable of analyzing underground remedies.

“With regular drugs, we know what the side effects and interactions are,” said Dr. Sarvesh Parikh, a resident at St. John’s, who wrote a note in Mr. Zhao’s chart about his roommates’ account of the pills. “About these kinds of pills, we don’t know anything.”

The larger mystery was why Mr. Zhao, a thin, quiet, frugal man, had gone without medical care instead of returning to Bellevue. In 2000, seven years after he and his brother arrived on American shores, jammed into the fetid hold of a smuggling ship, Bellevue doctors had diagnosed and eradicated his nasal cancer.

But even when treatment is a medical triumph, without sick pay or a safety net it can be personally devastating. In Mr. Zhao’s case, the effects of surgery, radiation and chemotherapy left him unable to work. His wife and son in China had counted on his income, and without it, she divorced him to marry another man. Then staggering medical bills arrived at the apartment that he and his brother shared with six roommates.

Medicaid reimburses hospitals for emergency care of the poor, regardless of immigration status. Outside of emergency care, however, illegal immigrants like Mr. Zhao are ineligible for Medicaid; in two-thirds of states, so are most legal noncitizens, no matter how indigent.

James Saunders, a spokesman for Bellevue, like Debby Cohen, a spokeswoman for St. John’s, said confidentiality laws barred discussion of Mr. Zhao’s case. But Mr. Saunders emphasized that Bellevue has a mandate not to turn anyone away because of immigration status or lack of money, “and an obligation to the federal government to collect what we can.”

After the Sept. 11 attacks, about the same time Bellevue security guards began demanding ID cards, clerks started collecting sliding-scale fees from the uninsured. Mr. Zhao was charged $20 per visit, then $150 for a CAT scan. Destitute, intimidated, unable to keep borrowing such sums, and unaware that the fees could be waived, his brother said, Mr. Zhao gave up on Bellevue in 2002.

“The doctor said that he was supposed to come back every two months, every three months, every six months, until the end of his life,” Ming Tong Zhao recalled through an interpreter. “But he couldn’t go back, because he couldn’t pay.”

By the time Mr. Zhao again ended up in a hospital, he was in a coma; just his intensive care bed, at St. Mary’s and then at St. John’s, cost Medicaid $5,400 a day. For more than a month, a parade of doctors did spinal taps, EKG’s, CAT scans and an M.R.I.; infused him with antibiotics, anticonvulsants and blood thinners; and placed him on a ventilator. Tests showed diabetes and high blood pressure, though their role in his collapse was uncertain.

Ming Tong, visiting between his work renovating kitchens in Manhattan, could not get a clear answer about what was wrong with his brother and was afraid to press. “You understand,” he said, “people in the United States without legal status don’t want to cause too much trouble.”

Afraid to Seek Help

Whether legal or illegal ・and many immigrant families include members in both categories ・noncitizens are fearful of asking for too much. Many echo Catalina, a Queens woman from Colombia who hesitated to sign her toddler up for the free speech therapy urged by his pediatrician because she and her husband had a pending application for a green card. “It scared us,” the woman said, “because if you are asking for residency, you have to show you are capable of living here without any help.”

Noncitizens are two to three times more likely to lack health insurance than citizens, studies show, and the gap has widened, even for children. Even legal immigrants qualified for government medical coverage often think twice about accepting it.

Special concerns arise among different ethnic groups. Korean parents in Staten Island mistakenly fear that their children will forfeit future chances for a college loan, said Jinny J. Park, a health specialist at Korean Community Services. And mothers at the Latin American Integration Center in Queens worry unnecessarily that free medical care will later mean their children’s military conscription. As one, Melosa, put it, “Everything we receive from the government is like giving my children away little by little” to the Army.

The changing political climate makes it hard to separate myth from reality. Laws codify disapproval of government aid for noncitizens. An immigrant deemed “likely to become a public charge,” for example, is to be denied a green card as undesirable. The 1996 welfare overhaul barred most legal immigrants who arrived after August of that year from receiving federal Medicaid until they become citizens, and the state-by-state patchwork of exceptions is confusing.

Even New York, which extends Medicaid to lawful immigrants and to low-income children regardless of status, reserves the right to sue their sponsoring relatives for reimbursement, though it is not doing so.

Those who do apply for public insurance discover a stark gap between the enthusiastic multilingual marketing of H.M.O.’s and the Kafkaesque task of getting and keeping an insurance card that works. They tell of learning only in the doctor’s office that a sick child’s card is not valid and then being turned away for lack of money.

The public health implications alarm James R. Tallon, president of the United Hospital Fund, a nonprofit policy group in New York. “Anything that keeps anyone away from the health system makes no sense at all,” Mr. Tallon said, noting that early detection is crucial in case of Avian flu or bioterrorism. “It takes one epidemic to change everyone’s attitudes about this.”

In some cases, the change in attitude comes instead from immigrants who arrived with high expectations of American medicine and now yearn for the kind they left back home. Yelena Deykin, a legal refugee who came from Ukraine in 2000, said that if she had the money, she would take her son back there for treatment of his thyroid ailment. “Our doctor not like your doctor,” she said. “Altruism ・not business.”

In Mr. Zhao’s hospital room, visitors began to hope for his recovery. After three weeks, he seemed responsive when they called his name. So it came as a shock when Mr. Chung, the waiter acting as a translator, relayed a new request from a doctor: Would they agree to let Mr. Zhao die?

Mr. Chung, who would soon return to work at an Asian restaurant in South Charleston, W.Va., translated the request for a “do not resuscitate” order as best he could, and drew his own conclusions. “Maybe some people don’t like Chinese,” he said.

Ming Tong refused to sign the order, then telephoned his brother’s son, in China, and asked him to decide. The son wept. Now 23, he had been a child of 9 when he last saw his father. As they discussed it again on Aug. 9, Mr. Zhao grew agitated. He tried to pull free of his tubes and his oxygen mask, as though he wanted to speak. Instead, despite resuscitation efforts, he died without a word.

In the End, No Answers

“The one thing that he wanted the most in his life was to see his son again, and he didn’t even get that chance,” Ming Tong said. “Why did he die? I asked the doctors. They didn’t know. They didn’t answer me.”

For immigrants, the divide of language and culture often deepens after death. In this case, doctors requested an autopsy. Ming Tong refused, in keeping with Chinese tradition. Doctors certified the death as natural, not mentioning the pills. The official cause of death was lobar pneumonia and sepsis, secondary to diabetes and hypertension ・acute lung and blood infections, that can attack patients on ventilators, but whose origins in this case are unknown, and chronic conditions that weaken the system.

On Aug. 13, The World Journal, a Chinese-language newspaper circulating to 300,000 in North America, described Mr. Zhao’s death as part of a pattern of fatal misdiagnoses and wrong medications given by unlicensed practitioners on East Broadway, the thoroughfare of Fujianese Chinatown.

But at the Medical Examiner’s Office, where an inquiry could have been ordered, no one reads Chinese and no one was aware of questions about the case. Permission for cremation was granted the next day.

Most of Mr. Zhao’s possessions fit into his coffin. The rest, including the pills, were discarded. But a woman going to his funeral called The New York Times and accused an unlicensed practitioner on East Broadway of mishandling Mr. Zhao’s case.

A decade ago, the Chinese American Medical Society helped spur a short-lived state crackdown on a Chinatown subculture of fake doctors. But “there are more illegal doctors than ever now,” said Dr. Peter Fong, an ophthalmologist and a former vice president of the society. They are not just offering herbal supplements, for which no license is required, he said, but practicing medicine without a license ・a crime.

To John C. Liu, the first Asian-American elected to the New York City Council, the reason is obvious: “What empowers the quacks is lack of access to health care.”

Chinese workers scattered in jobs throughout New York and across the country periodically return to East Broadway, the hub of Fujianese life in the United States, to find health care ・of a sort.

No. 52, where Mr. Chung says he accompanied Mr. Zhao last summer and saw the dispensing of the pills, is stacked with self-styled clinics. One thrives at the back of a basement computer store; another features $30 pregnancy sonograms and a crookedly lettered sign for “precise dental art.”

The establishment of Yu Yuan Zhang, 50, where Mr. Chung said he and Mr. Zhao went, has operated for 11 years. Near drawers of Chinese herbs hangs a New York State medical license ・in someone else’s name. Visibly nervous, Mr. Zhang denied that any pills he dispensed could cause harm. “They’re made in China,” he said, “available all over, in the street.”

By then, the only evidence left of Mr. Zhao’s 12 years in the United States were bills, ashes and a death certificate that his brother could not read. Pressed about the case, the practitioner did not hesitate.

“There is no such person,” he said. “There is no Ming Qiang Zhao.”

More community health centers, but fewer clinicians

Shortages of Medical Personnel at Community Health Centers Implications for Planned Expansion
By Roger A. Rosenblatt, MD, MPH; C. Holly A. Andrilla, MS; Thomas Curtin, MD; L. Gary Hart, PhD
JAMA
March 1, 2006

Residents of the United States lack universal access to health care, and millions of people have difficulty obtaining medical care. The year 2005 marked the 40th anniversary of one of the nation’s most enduring attempts to remedy this problem: the creation of community health centers (CHCs) as part of the “war on poverty.”

The role and responsibility of CHCs have increased as more people in the United States have difficulty gaining access to medical care. CHCs now provide care to more than 14 million US residents in more than 3500 communities. Governed by nonprofit boards with majority representation from the patient population served, CHCs are different from the private practices and for-profit entities that deliver most ambulatory care in the United States.

A national decision to invest further in CHCs has occurred during a period when access to health care in the United States is limited for more people than ever before in the country’s history.

Our results show that in 2004, CHCs were understaffed and were having difficulty recruiting essential health care personnel. This inability to fill budgeted vacancies could become a rate-limiting factor as they seek to expand their clinical activities to care for needy populations, particularly in rural areas.

The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians. This is occurring in a national environment in which primary care in general has lost popularity as a practice discipline. For example, the US production of family physicians has decreased rapidly in the last 7 years, with the number of US medical graduates matching in family medicine declining 51.6% from 1997 to 2005. Filling the existing CHC vacancies would absorb 20% of the 2005 output from the family medicine residencies.

Conclusions: CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues.

http://jama.ama-assn.org/cgi/content/full/295/9/1042#REF-JOC60013-9

Comment: By Don McCanne, M.D.

Expanding community health centers seems to be an almost futile exercise when the primary care workforce is contracting.

What can be done, under our current system of funding health care, to address this problem? On the other hand, what might the public administrator of a single payer monopsony do if presented with this same problem? More importantly, would this degree of deterioration of the primary care workforce have been allowed to happen under a single payer system?