PNHP

Health care reform urged

Health care reform urged

Speakers at town hall meeting call for universal coverage through government program

By Patrick Cain
Special to the Times Union
Thursday, December 15, 2005

ALBANY, New York — Medicaid referrals aren’t easy for Dr. Paul Sorum.

“I virtually throw my hands up trying to find a provider” who will accept payment through the government insurance program for the poor, said Sorum, chair of the Capital District chapter of Physicians for a National Health Program. “We want to treat not only some of our patients but all of our patients.”

Sorum spoke recently at a town hall meeting at which doctors, governmental officials, advocates and local residents shared their concerns about the need for health care reform. The event drew about 70 people.

“We’re headed in the wrong direction,’ said Dr. Glenn McGee, director of the Alden March Bioethics Institute at Albany Medical College. He and others who spoke backed a bill on Capitol Hill, HR 676, which would provide universal health care coverage.

The measure would be good for Albany resident Beeca Leet, who explained her circumstances. She said she spends more than $600 a month on medication — that’s half of what she earns, which is too much to qualify for government services, but not enough to meet her medical needs.

U.S. Rep. Michael McNulty, a co-sponsor of HR 676 in the House of Representatives, was pessimistic about its chances for passage. “With the Bush White House and a Republican-controlled Congress, the bill doesn’t have a chance,” said McNulty, a Green Island Democrat. Slamming his fist on the table, McNulty expressed anger that some people resort to cutting their pills in half. “I have people in my office tell me they do this to make their prescription last longer,” he said.

Erick Cheung, a third-year student at Albany Medical College, equated today’s health care system with an obsolete classic. “You can’t make a Model-T fly,” he said.

Kitzhaber's Rx for state

In eyeing a new run for governor, he thinks on a revolutionary scale
By David Steves
The Register-Guard, Eugene, Oregon
Saturday, December 17, 2005

The last time John Kitzhaber put Oregon on the map as a health care pioneer, it was by working within the decades-old system that delivers medical care. This time, the former doctor and governor wants to bulldoze what he sees as an antiquated system and replace it with a 21st-century model that would deliver universal health care to every Oregonian.

It’s a big enough idea to have Kitzhaber publicly contemplating a return to the governor’s office, where he says he could see it to fruition. That effort probably would involve ballot-measure or legislative campaigns. It also would be likely to involve the enlistment of Oregon’s congressional delegation and the White House to let Oregon out of the 20th-century rules of federal Medicare and Medicaid spending and to end tax exemption for employer-provided health insurance.

Kitzhaber on Friday said he plans to meet next week with Gov. Ted Kulongoski to discuss his health care ambitions and his interest in challenging Kulongoski in next May’s Democratic primary. The ex-governor said Friday he also has met with state teachers union officials, business leaders and others as he contemplates a political comeback.

Regardless of whether he runs for governor – something he plans to decide on next month – Kitzhaber said he wants to champion reforms. That could mean a ballot measure in 2006 or 2008 or a push for legislation in 2007 through the Legislature, he said.

In an hourlong interview Friday to discuss his ideas for reforming the health care system, Kitzhaber said he wants to start a national movement toward universal health care by designing a system for Oregon that would provide basic care to everyone.

After leaving office in January 2003 and getting involved with national health care research and education programs, Kitzhaber has observed rapidly gathering storm clouds. Health care costs are rising. Employers and governments are dropping coverage for workers, driving a growing number of uninsured people to emergency departments with chronic health problems that get shifted back onto insurance premium costs. The Medicare program, a federal entitlement that can’t be easily cut, is about to be swamped by aging, ailing baby boomers, resulting in trillions of dollars in national debt.

“I think it’s just terrifying,” Kitzhaber said. “That’s the situation, and clearly, something needs to be done. And I think it needs to be done very, very soon because this is really coming down right now.”

Kitzhaber once called Oregon “ungovernable” as he prepared to leave the state’s highest office. But Friday he exuded optimism as he described the enthusiastic reception he’s received while meeting with national audiences and in-state advisers from business, labor and the health care industry.

“People are looking for a place to engage in this debate,” he said.

Kitzhaber described a two-pronged goal: to actually bring universal health care to Oregon, and to force the debate at the national level – in Congress and perhaps even the 2008 presidential campaigns.

A rationing system

Kitzhaber made a mark in health care reform with the Oregon Health Plan, which he designed as Senate president in the 1980s and shepherded along while governor in 1995-2003. The health plan expanded the number of people who qualified for Medicaid by getting the federal government’s blessing to modestly limit care and to use the savings to let low-income people who didn’t fit into a Medicaid-eligible category – they weren’t elderly, blind, or pregnant women, for instance – get coverage.

This time, Kitzhaber says he wants to go much farther. Instead of dealing with those “working poor” who fall through the cracks, he envisions a basic coverage plan for all Oregonians – those who currently get coverage through work, those who aren’t insured, and those who qualify for government coverage such as Medicare.

How would Oregon pay for universal health care? Kitzhaber said his idea is to continue using the public dollars already going into Oregon’s system of delivering medical care, without raising taxes.

One element would be to persuade the federal government to remove its strings for how Medicaid and Medicare dollars are spent and put them into the universal health care pot.

Added to that would be the tax dollars that currently go uncollected on the money that employers pay for workers’ medical insurance premiums. The idea here – which Kitzhaber has yet to fully flesh out – is that employer-provided health care is a form of tax-exempt compensation to workers, a practice that began during the wage-control era of World War II and was added to the tax code in 1954.

With universal coverage, employers would not need to buy insurance for their workers. So, employers could use that money instead to pay wages, which would remove the tax exclusion currently available under state and federal law. Kitzhaber calls the current tax exemption a subsidy paid by all U.S. residents amounting to $200 billion a year.

With that combination, Oregon would have about $6.3 billion a year to pay for universal health care.

Per capita, that $6.3 billion would break down to about $2,000 per Oregonian. That’s not enough to cover everyone’s basic needs, Kitzhaber said, given the inefficiency of Oregon’s current medical care delivery system – doctors’ practices, private and government-sponsored health insurance, hospitals and clinics.

But if the state replaced that system with one designed from scratch, guided by the principle of maximizing Oregonians’ health in the most cost-effective way, it would be enough, he said. He said Italy achieves better health outcomes than does the United States at a cost of about $2,000 per person.

Designing a new system

Kitzhaber said his new system would deliver basic health care to all Oregonians – from private-sector employees to retirees, children, and the poor.

That step would involve scrapping everything about the current system – employer-provided medical coverage rooted in the 1940s, and 1960s-era Medicaid and Medicare programs. He said he’d model a new system on other public services, such as education, police and fire – services that all citizens are entitled to, regardless of where they live, their incomes, or other factors.

Using the education system as an analogy, Kitzhaber envisions a basic level of care that everyone would be eligible for. Just as those with the resources can seek out more specialized education through private schooling, so could individuals buy insurance for things not covered by the universal health care program, he said.

Continuing coverage for those currently receiving it and adding it for the 609,000 Oregonians who lack insurance would be costly.

But Kitzhaber said he thinks it could be done using existing public health care dollars and increasing the efficiency of hospitals, doctors and clinics.

For instance, if all Oregonians were entitled to medical coverage, it would be easier to ensure that people with high blood pressure get moderately priced instruction and monitoring to reduce and control the condition, rather than leaving it untended until they suffer strokes and require expensive care, he said.

Any such reforms would need federal approval. But Kitzhaber said he has no interest in pursuing them by running for the U.S. Senate – something he was urged to do in 2002, but rejected. He said he would prefer to launch such a system at the state level, then push it nationally.

“I could be a U.S. senator today and I couldn’t do anything about this, unless my state or some state actually blew in something that we had to deal with,” he said. “It doesn’t start there. That’s where it ends, but it’s got to start outside.”

Public or private role?

Kitzhaber doesn’t rule out that another governor might be able to champion his reforms, or that he could do so himself from outside government.

Up to now, Kitzhaber has been able to pursue his ideas as a private citizen, thanks to his expertise and stature in health care policy circles, as well as his involvement with health policy groups. He holds various posts at academic and medical organizations where he is developing his ideas.

Kitzhaber said he began to consider running for governor earlier this year.

Republican lawmakers who remember Kitzhaber as a governor who was quick to veto their bills and reluctant to compromise said it’s difficult to imagine him succeeding in a bid.

“You’ll have to do a lot more convincing for me to believe that he is really serious about being chief executive and dealing with the whole universe of challenges facing Oregon,” said Senate Republican Leader Ted Ferrioli of John Day, citing land use, employment issues and housing. “I think it’s inappropriate for him to even consider a run for the governorship if he’s just trying to use it as a bully pulpit to frame health care issues.”

But independent Portland-based pollster Adam Davis said Kitzhaber’s re-emergence is well timed, given his credibility on health care and the voters’ demands for change.

Health care “is the sleeping giant of issues right now. The whole cluster of health care quality and health care costs is really very much on the minds of Oregonians and is an issue that we see showing up over and over again as a big blinking dot on the radar screen,” he said. “It’s interesting that you have a guy like Kitzhaber. He just happens to be the guy who’s most qualified to talk on this issue. I think he would have credibility on it.”

Kitzhaber said running for governor could hurt his health care reform cause.

“You politicize the issue if you run,” he said.

Kitzhaber said if he does run, health care would be his big campaign issue. But he said other concerns, such as education and the economy, would be on his agenda. But reforming Oregon’s health care system is critical, he said.

“Health care is impacting our ability to grow our economy,” he said. “It’s impacting our ability to invest in education.”

He said his critics will prevail if they can seize on certain details and fuel voters’ skepticism about taxes, spending and the loss of a system that serves some people – those with good medical coverage – very well.

Kitzhaber said his message “has to be about empowerment – that we don’t have to wait for the future … that we can step up and actually take care of ourselves.”

HEALTH CARE CRISIS

Numbers that point to what many, including former Gov. John Kitzhaber, see as an impending crisis in health care.

Oregon Health Plan coverage:
2002: 475,000 people (including 109,000 on OHP Standard)
2005: 409,000 (including 25,000 on OHP Standard)
Oregonians without health insurance
1996: 11 percent
2002: 14 percent
2004: 17 percent

Bankruptcy:
50 percent of U.S. households declaring bankruptcy cite medical causes; 76 percent had medical insurance at onset of illness.

Insurance premiums:
Average annual cost: $10,800
Employees’ average share: $2,713
Employees’ increase from 2004: 9.2 percent
Employees’ wage increase from 2004: 2.7 percent
Employees’ premium increases since 2000: 73 percent

Decline in employer-provided medical coverage:
1990-2000: Employers providing coverage declines by 2 percent a year.
Since 2000: Employers providing coverage declines by 4 percent a year.

Federal safety-net health care spending:
2001: $546 per uninsured person
2004: $498 per uninsured person

— Sources: Oregon Office of Health Policy & Research; Harvard law professor Elizabeth Warren; Kaiser Family Foundation; Portland Business Journal; Foundation for Medical Excellence

Congress’ gift for Tiny Tim

Budget Accord Could Mean Payments by Medicaid Recipients
By Robert Pear
The New York Times
December 20, 2005

The final Congressional agreement on a budget bill gives states sweeping new authority to impose premiums and co-payments on Medicaid recipients…

Under the agreement, states can charge premiums and higher co-payments for a wide range of Medicaid benefits, including prescription drugs, doctors’ services and hospital care.

States can scale back benefits, capping or eliminating coverage for services that federal law now guarantees.

In addition, states can end Medicaid coverage for people who fail to pay premiums for 60 days or more. Pharmacists can refuse to fill prescriptions, and doctors and hospitals can deny services, for recipients who do not make the required co-payments.

Medicaid recipients can be charged 10 percent of the cost of any item or service if their family incomes were 100 percent to 150 percent of the federal poverty level, $12,830 to $19,245 for a family of two. Recipients with incomes above that can be required to pay 20 percent of the cost of any item or service.

Drug makers and health insurance companies escaped largely unscathed. Negotiators rejected several provisions of the Senate bill that would have cut their payments.

Representative Joe L. Barton, Republican of Texas, the architect of the Medicaid provisions, said the higher co-payments were needed to “encourage personal responsibility” among low-income people.

http://www.nytimes.com/2005/12/20/politics/20health.html

Comment: In the glorious spirit of Christmas, Congress is extending policies that shower gifts on the health insurance industry and pharmaceutical firms.

And for Tiny Tim? They are giving him the gift of “personal responsibility.” He can go out and get his own damn crutch!

Kitzhaber’s Rx for state

In eyeing a new run for governor, he thinks on a revolutionary scale
By David Steves
The Register-Guard, Eugene, Oregon
Saturday, December 17, 2005

The last time John Kitzhaber put Oregon on the map as a health care pioneer, it was by working within the decades-old system that delivers medical care. This time, the former doctor and governor wants to bulldoze what he sees as an antiquated system and replace it with a 21st-century model that would deliver universal health care to every Oregonian.

It’s a big enough idea to have Kitzhaber publicly contemplating a return to the governor’s office, where he says he could see it to fruition. That effort probably would involve ballot-measure or legislative campaigns. It also would be likely to involve the enlistment of Oregon’s congressional delegation and the White House to let Oregon out of the 20th-century rules of federal Medicare and Medicaid spending and to end tax exemption for employer-provided health insurance.

Kitzhaber on Friday said he plans to meet next week with Gov. Ted Kulongoski to discuss his health care ambitions and his interest in challenging Kulongoski in next May’s Democratic primary. The ex-governor said Friday he also has met with state teachers union officials, business leaders and others as he contemplates a political comeback.

Regardless of whether he runs for governor – something he plans to decide on next month – Kitzhaber said he wants to champion reforms. That could mean a ballot measure in 2006 or 2008 or a push for legislation in 2007 through the Legislature, he said.

In an hourlong interview Friday to discuss his ideas for reforming the health care system, Kitzhaber said he wants to start a national movement toward universal health care by designing a system for Oregon that would provide basic care to everyone.

After leaving office in January 2003 and getting involved with national health care research and education programs, Kitzhaber has observed rapidly gathering storm clouds. Health care costs are rising. Employers and governments are dropping coverage for workers, driving a growing number of uninsured people to emergency departments with chronic health problems that get shifted back onto insurance premium costs. The Medicare program, a federal entitlement that can’t be easily cut, is about to be swamped by aging, ailing baby boomers, resulting in trillions of dollars in national debt.

“I think it’s just terrifying,” Kitzhaber said. “That’s the situation, and clearly, something needs to be done. And I think it needs to be done very, very soon because this is really coming down right now.”

Kitzhaber once called Oregon “ungovernable” as he prepared to leave the state’s highest office. But Friday he exuded optimism as he described the enthusiastic reception he’s received while meeting with national audiences and in-state advisers from business, labor and the health care industry.

“People are looking for a place to engage in this debate,” he said.

Kitzhaber described a two-pronged goal: to actually bring universal health care to Oregon, and to force the debate at the national level – in Congress and perhaps even the 2008 presidential campaigns.

A rationing system

Kitzhaber made a mark in health care reform with the Oregon Health Plan, which he designed as Senate president in the 1980s and shepherded along while governor in 1995-2003. The health plan expanded the number of people who qualified for Medicaid by getting the federal government’s blessing to modestly limit care and to use the savings to let low-income people who didn’t fit into a Medicaid-eligible category – they weren’t elderly, blind, or pregnant women, for instance – get coverage.

This time, Kitzhaber says he wants to go much farther. Instead of dealing with those “working poor” who fall through the cracks, he envisions a basic coverage plan for all Oregonians – those who currently get coverage through work, those who aren’t insured, and those who qualify for government coverage such as Medicare.

How would Oregon pay for universal health care? Kitzhaber said his idea is to continue using the public dollars already going into Oregon’s system of delivering medical care, without raising taxes.

One element would be to persuade the federal government to remove its strings for how Medicaid and Medicare dollars are spent and put them into the universal health care pot.

Added to that would be the tax dollars that currently go uncollected on the money that employers pay for workers’ medical insurance premiums. The idea here – which Kitzhaber has yet to fully flesh out – is that employer-provided health care is a form of tax-exempt compensation to workers, a practice that began during the wage-control era of World War II and was added to the tax code in 1954.

With universal coverage, employers would not need to buy insurance for their workers. So, employers could use that money instead to pay wages, which would remove the tax exclusion currently available under state and federal law. Kitzhaber calls the current tax exemption a subsidy paid by all U.S. residents amounting to $200 billion a year.

With that combination, Oregon would have about $6.3 billion a year to pay for universal health care.

Per capita, that $6.3 billion would break down to about $2,000 per Oregonian. That’s not enough to cover everyone’s basic needs, Kitzhaber said, given the inefficiency of Oregon’s current medical care delivery system – doctors’ practices, private and government-sponsored health insurance, hospitals and clinics.

But if the state replaced that system with one designed from scratch, guided by the principle of maximizing Oregonians’ health in the most cost-effective way, it would be enough, he said. He said Italy achieves better health outcomes than does the United States at a cost of about $2,000 per person.

Designing a new system

Kitzhaber said his new system would deliver basic health care to all Oregonians – from private-sector employees to retirees, children, and the poor.

That step would involve scrapping everything about the current system – employer-provided medical coverage rooted in the 1940s, and 1960s-era Medicaid and Medicare programs. He said he’d model a new system on other public services, such as education, police and fire – services that all citizens are entitled to, regardless of where they live, their incomes, or other factors.

Using the education system as an analogy, Kitzhaber envisions a basic level of care that everyone would be eligible for. Just as those with the resources can seek out more specialized education through private schooling, so could individuals buy insurance for things not covered by the universal health care program, he said.

Continuing coverage for those currently receiving it and adding it for the 609,000 Oregonians who lack insurance would be costly.

But Kitzhaber said he thinks it could be done using existing public health care dollars and increasing the efficiency of hospitals, doctors and clinics.

For instance, if all Oregonians were entitled to medical coverage, it would be easier to ensure that people with high blood pressure get moderately priced instruction and monitoring to reduce and control the condition, rather than leaving it untended until they suffer strokes and require expensive care, he said.

Any such reforms would need federal approval. But Kitzhaber said he has no interest in pursuing them by running for the U.S. Senate – something he was urged to do in 2002, but rejected. He said he would prefer to launch such a system at the state level, then push it nationally.

“I could be a U.S. senator today and I couldn’t do anything about this, unless my state or some state actually blew in something that we had to deal with,” he said. “It doesn’t start there. That’s where it ends, but it’s got to start outside.”

Public or private role?

Kitzhaber doesn’t rule out that another governor might be able to champion his reforms, or that he could do so himself from outside government.

Up to now, Kitzhaber has been able to pursue his ideas as a private citizen, thanks to his expertise and stature in health care policy circles, as well as his involvement with health policy groups. He holds various posts at academic and medical organizations where he is developing his ideas.

Kitzhaber said he began to consider running for governor earlier this year.

Republican lawmakers who remember Kitzhaber as a governor who was quick to veto their bills and reluctant to compromise said it’s difficult to imagine him succeeding in a bid.

“You’ll have to do a lot more convincing for me to believe that he is really serious about being chief executive and dealing with the whole universe of challenges facing Oregon,” said Senate Republican Leader Ted Ferrioli of John Day, citing land use, employment issues and housing. “I think it’s inappropriate for him to even consider a run for the governorship if he’s just trying to use it as a bully pulpit to frame health care issues.”

But independent Portland-based pollster Adam Davis said Kitzhaber’s re-emergence is well timed, given his credibility on health care and the voters’ demands for change.

Health care “is the sleeping giant of issues right now. The whole cluster of health care quality and health care costs is really very much on the minds of Oregonians and is an issue that we see showing up over and over again as a big blinking dot on the radar screen,” he said. “It’s interesting that you have a guy like Kitzhaber. He just happens to be the guy who’s most qualified to talk on this issue. I think he would have credibility on it.”

Kitzhaber said running for governor could hurt his health care reform cause.

“You politicize the issue if you run,” he said.

Kitzhaber said if he does run, health care would be his big campaign issue. But he said other concerns, such as education and the economy, would be on his agenda. But reforming Oregon’s health care system is critical, he said.

“Health care is impacting our ability to grow our economy,” he said. “It’s impacting our ability to invest in education.”

He said his critics will prevail if they can seize on certain details and fuel voters’ skepticism about taxes, spending and the loss of a system that serves some people – those with good medical coverage – very well.

Kitzhaber said his message “has to be about empowerment – that we don’t have to wait for the future … that we can step up and actually take care of ourselves.”

HEALTH CARE CRISIS

Numbers that point to what many, including former Gov. John Kitzhaber, see as an impending crisis in health care.

Oregon Health Plan coverage:
2002: 475,000 people (including 109,000 on OHP Standard)
2005: 409,000 (including 25,000 on OHP Standard)
Oregonians without health insurance
1996: 11 percent
2002: 14 percent
2004: 17 percent

Bankruptcy:
50 percent of U.S. households declaring bankruptcy cite medical causes; 76 percent had medical insurance at onset of illness.

Insurance premiums:
Average annual cost: $10,800
Employees’ average share: $2,713
Employees’ increase from 2004: 9.2 percent
Employees’ wage increase from 2004: 2.7 percent
Employees’ premium increases since 2000: 73 percent

Decline in employer-provided medical coverage:
1990-2000: Employers providing coverage declines by 2 percent a year.
Since 2000: Employers providing coverage declines by 4 percent a year.

Federal safety-net health care spending:
2001: $546 per uninsured person
2004: $498 per uninsured person

— Sources: Oregon Office of Health Policy & Research; Harvard law professor Elizabeth Warren; Kaiser Family Foundation; Portland Business Journal; Foundation for Medical Excellence

The inefficiency of tax credits for private insurance

Health Care for All, Just a (Big) Step Away
By Eduardo Porter
The New York Times
December 18, 2005

Next year, the federal government expects to provide about $130 billion for Americans to buy health insurance (through the tax break for employer-sponsored coverage).

Although subsidizing health insurance may seem a worthy effort, a positive contribution to the goal of universal coverage, it is among the most inefficient spending in the nation’s fiscal arsenal.

… if the objective is to expand health care coverage, a bolder option is available: focusing the bulk of the money on the bottom end of the income distribution.

Added to what is already spent on Medicaid, this financing would be roughly enough to make health insurance free for people earning up to three times the poverty level, and perhaps somewhat more, said Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology who has studied the efficiency of alternative methods for financing health insurance.

To make insurance universal, two other things would be needed, Mr. Gruber said. As soon as the tax break was eliminated, company-provided health insurance would be likely to disappear, too. So some mechanism would be needed to pool groups of people and to avoid leaving higher-risk people to face enormous insurance costs. Such a mechanism would probably make health insurance affordable for all. And to make it universal, a mandate would be needed to make people buy it.

http://www.nytimes.com/2005/12/18/business/yourmoney/18view.html?pagewanted=all

And…

Tax Policy for Health Insurance
By Jonathan Gruber
National Bureau of Economic Research
December 2004

Despite a $140 billion existing tax break for employer-provided health insurance, tax policy remains the tool of choice for many policy-makers in addressing the problem of the uninsured. In this paper, I use a microsimulation model to estimate the impact of various tax interventions to cover the uninsured, relative to an expansion of public insurance designed to accomplish the same goals. I contrast the efficiency of these policies along several dimensions, most notably the dollars of public spending per dollar of insurance value provided. I find that every tax policy is much less efficient than public insurance expansions: while public insurance costs the government only between $1.17 and $1.33 per dollar of insurance value provided, tax policies cost the government between $2.36 and $12.98 per dollar of insurance value provided. I also find that targeting is crucial for efficient tax policy; policies tightly targeted to the lowest income earners have a much higher efficiency than those available higher in the income distribution.

http://www.nber.org/papers/w10977

Comment: Professor Gruber has demonstrated that a tax-payer funded government insurance program would be a far more efficient use of public dollars than tax-payer funded tax credits for the purchase of either employer-sponsored or individual private insurance plans. Even targeted tax credits for private insurance are much less efficient than tax-funded public programs.

Those who insist that we should use policies supporting private insurance to expand coverage do recognize the inequities of their proposals. Realizing that low-income individuals cannot afford reasonable coverage, they have recommended tax credits that are specifically targeted to this sector. Without considering all of the other inefficiencies and inequities of private insurance, Dr. Gruber’s work should lead to the conclusion that private insurance approaches should be abandoned as being a terrible waste of public dollars.

It is true that a publicly-funded, universal insurance program would increase public spending, but the important difference is that it would provide greater insurance value by eliminating many of the inefficiencies and inequities of our fragmented public/private system, thereby improving overall efficiency.

Not only those on the right want to see an efficient system, and not only those on the left want to see an equitable system. It seems that equity and efficiency should provide us with a common ground for crafting reform.

Universal medicare: TV is listening; what about Washington?

A reader writes, “What are your thoughts about the statement by Matt Santos, the Democratic presidential nominee on TV’s ‘The West Wing,’ that extending Medicare to all Americans would be an inexpensive and effective way of providing national health insurance?”

My first thought is what Matt Santos might have been reading lately.

It’s possible he was reading one of my old columns, for example, http://www.lansingcitypulse.com/030212/health2/index.html. There I mentioned that both the UAW and General Motors had concluded that national health insurance was the best way to get the auto industry to stop hemorrhaging red ink (and that was well before recent bankruptcies and plant closings).

Or else Santos might have been perusing the recent columns by Paul Krugman of The New York Times, who, I admit, gets a bit more exposure. Krugman has been teaching his readers a crash course in Health Economics 101 and basically saying that no matter how you add up the numbers, some sort of single-payer national insurance makes the most sense.

Finally, ol’ Matt may have been paying attention to the literature put out by the Physicians for a National Health Program. For some years they have been talking about “universal Medicare,” and it’s from them that I picked up the phrase to use in my 2003 column. The thinking is that we need some sort of single-payer national health insurance. But if we call it “Canadian style single-payer,” it’s a non-starter right away in the U.S. political landscape. Medicare, as we have seen in the last couple of years, is extremely popular; even the most-far-right conservatives are afraid to mess with it too much. And it just so happens that Medicare is the closest thing we have in the United States to a single payer system, even though it serves only a part of the population. So maybe “universal Medicare” is the way to get the average Joe on the street to think about it.

What about Santos’ claims that this will save money? Lots of people have done that math too, and it keeps coming out favorably. We continue to believe the myth that the government is inherently inefficient and the private sector is a model of efficiency. The administration of the Medicare program costs about 3 percent of total revenues. The average U.S. private health insurer spends between 15percent and 25 percent of revenues on administrative overhead and bureaucracy. It’s been frequently estimated that switching to a single-payer system would immediately save the U.S. some $150 to 200 billion annually, which is enough to provide good health care for all of those now uninsured.

By contrast, no one advocating a “free market” solution to the U.S. health care implosion has been able to come up with a plan that will both provide universal access and also control costs.

The proof seems to lie in the international experience. The most developed nations of the world all manage to provide high quality care for all their citizens while spending around 8-9 percent of their GDP to do it. All have some sort of nationally-run or at least nationally-coordinated plan, though some, like Germany, are not true single-payer.

The United States is the sole outlier. We leave about 46 million uninsured, or up to 80 million if you count those who lack insurance for at least part of a two-year period. We spend 15 percent of GDP on this boondoggle. And for all that, we get a health care system that on recent international charts ranks around 30th in the world, somewhere around Slovenia’s.

Experts in health policy have been saying this for years. Now the TV politicians appear to be saying it. When are the real politicians going to speak up?

(Howard Brody is a family practice physician and professor of medical ethics at MSU.)

Aetna's Rowe on high-deductible coverage

Consumer-Directed Health Insurance: The Next Generation
An interview: John Rowe, a physician, is chairman and chief executive officer of Aetna, one of the nation’s largest insurance companies. James Robinson is the Kaiser Permanente Distinguished Professor of Health Economics at the University of California, Berkeley, School of Public Health.
Health Affairs
December 13, 2005

The Limits Of High Deductibles

Robinson: One of the criticisms of high-deductible products is that they are financially more onerous to high users of care than they are to the healthy. Healthy people don’t need much medical care, and so they won’t use much, whereas sick people do need medical care, and they spend more. High-deductible products reduce the subsidy from the healthy to the sick that operates through low-deductible health insurance.

Rowe: At this point, you know, we’re talking about two percent or so of the insurance pool being enrolled in these products, and so we haven’t reached the tipping point.

Robinson: How far, as you and your colleagues think about this, will the deductibles increase?

Rowe: Employers are still raising them. We haven’t hit the limit of cost sharing… Some people consider increases in the deductible to be a bad sign and believe there will be significant pushback from employees and that it won’t go much higher. But my sense is that for many employers, raising the deductible is the alternative to not offering insurance at all. And so I would not be surprised to see much higher deductibles in the small-business and middle markets. I don’t think you’ll see that in the larger corporate accounts, however.

We’re talking as if the products are uniform in the marketplace in high-deductible health plans, but they are not. In the market you see two very different types. You see plans such as the Aetna plan where the deductibles are moderate and where preventive services and medications and other things are out of the deductible and reimbursed on a first-dollar basis. But then you can also find, on the Internet, products with a $10,000 deductible-very-high-deductible health plans with nothing out of the deductible [in terms of preventive services and drugs]. Those are not the kinds of products we at Aetna think are in people’s best interest. Those are not the products that we sell.

Robinson: That’s an interesting distinction.

Rowe: They are giving high-deductible health plans a bad name.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.583v1

Comment: Checking the Aetna website for California, plans available include, amongst others, California PPO 5000, California High-Deductible PPO2 (HSA Compatible), and California PPO Value 5000. If you remain within the Aetna network of providers, these plans have a deductible of $5,000 for individuals and $10,000 for families. For care obtained out-of-network, the deductibles are $10,000 for individuals and $20,000 for families (plus fees beyond Aetna’s allowable schedule). The only listed services for which the deductible is waived are an annual routine OB/GYN exam (but no maternity visits), and up to $200 for an annual physical with a $25 or $50 copay (though in some plans the pharmacy deductible may be lower).

These may not be the kinds of products that, in Dr. Rowe’s words, “we at Aetna think are in people’s best interest,” but they do sell them.

By pretending that Aetna is not part of the problem, I would say that Dr. Rowe is himself giving “health plans a bad name,” and quite deservedly so. Even the best of the private insurers are catering preferentially to insurance purchasers rather than patients, by marketing products that abandon their primary role of providing financial security for those with health-care needs.

Clearly it is time to dismiss the private insurers as the stewards of our health care dollars. By establishing our own, single-payer, national health insurance program, we would establish policies that would ensure that health-care dollars be spent on… health care!

Aetna’s Rowe on high-deductible coverage

Consumer-Directed Health Insurance: The Next Generation
An interview: John Rowe, a physician, is chairman and chief executive officer of Aetna, one of the nation’s largest insurance companies. James Robinson is the Kaiser Permanente Distinguished Professor of Health Economics at the University of California, Berkeley, School of Public Health.
Health Affairs
December 13, 2005

The Limits Of High Deductibles

Robinson: One of the criticisms of high-deductible products is that they are financially more onerous to high users of care than they are to the healthy. Healthy people don’t need much medical care, and so they won’t use much, whereas sick people do need medical care, and they spend more. High-deductible products reduce the subsidy from the healthy to the sick that operates through low-deductible health insurance.

Rowe: At this point, you know, we’re talking about two percent or so of the insurance pool being enrolled in these products, and so we haven’t reached the tipping point.

Robinson: How far, as you and your colleagues think about this, will the deductibles increase?

Rowe: Employers are still raising them. We haven’t hit the limit of cost sharing… Some people consider increases in the deductible to be a bad sign and believe there will be significant pushback from employees and that it won’t go much higher. But my sense is that for many employers, raising the deductible is the alternative to not offering insurance at all. And so I would not be surprised to see much higher deductibles in the small-business and middle markets. I don’t think you’ll see that in the larger corporate accounts, however.

We’re talking as if the products are uniform in the marketplace in high-deductible health plans, but they are not. In the market you see two very different types. You see plans such as the Aetna plan where the deductibles are moderate and where preventive services and medications and other things are out of the deductible and reimbursed on a first-dollar basis. But then you can also find, on the Internet, products with a $10,000 deductible-very-high-deductible health plans with nothing out of the deductible [in terms of preventive services and drugs]. Those are not the kinds of products we at Aetna think are in people’s best interest. Those are not the products that we sell.

Robinson: That’s an interesting distinction.

Rowe: They are giving high-deductible health plans a bad name.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.583v1

Comment: Checking the Aetna website for California, plans available include, amongst others, California PPO 5000, California High-Deductible PPO2 (HSA Compatible), and California PPO Value 5000. If you remain within the Aetna network of providers, these plans have a deductible of $5,000 for individuals and $10,000 for families. For care obtained out-of-network, the deductibles are $10,000 for individuals and $20,000 for families (plus fees beyond Aetna’s allowable schedule). The only listed services for which the deductible is waived are an annual routine OB/GYN exam (but no maternity visits), and up to $200 for an annual physical with a $25 or $50 copay (though in some plans the pharmacy deductible may be lower).

These may not be the kinds of products that, in Dr. Rowe’s words, “we at Aetna think are in people’s best interest,” but they do sell them.

By pretending that Aetna is not part of the problem, I would say that Dr. Rowe is himself giving “health plans a bad name,” and quite deservedly so. Even the best of the private insurers are catering preferentially to insurance purchasers rather than patients, by marketing products that abandon their primary role of providing financial security for those with health-care needs.

Clearly it is time to dismiss the private insurers as the stewards of our health care dollars. By establishing our own, single-payer, national health insurance program, we would establish policies that would ensure that health-care dollars be spent on… health care!

The fallacy of hospital price shopping

Price Check: The Mystery of Hospital Pricing
California HealthCare Foundation
December 2005

In 2004, the California Legislature passed… AB 1626, requiring hospitals to provide information to patients on fees for 25 common services and to post notices informing patients that information was available to them.

That same year, the California Hospital Association developed and encouraged member hospitals to adopt voluntary guidelines… that hospitals should have clearly stated written payment and financial assistance policies, that hospitals should post notices about these policies, and that hospitals should train staff on communicating these policies.

In an effort to evaluate hospital-pricing practices, the California HealthCare Foundation sent a group of would-be patients to 64 hospitals throughout California. These “mystery shoppers” posed as low-income, uninsured patients who needed to find a hospital for an upcoming test or procedure.

Key Findings

* Better systems are needed

* Getting a price can be a frustrating process

* Type of procedure partially determines whether hospitals provide a price

* Hospitals must expand training to ensure employees understand how to deliver pricing and payment information

* Hospital pricing information is inconsistent, making it difficult to shop for the best value

* Financial assistance can be a “Catch-22”

* Written notices communicating financial assistance are often inadequate or inaccessible

Although some of the shoppers had positive experiences, overall the project revealed a wide communications gap between hospitals and their patients – a gap that has poor implications for patients who must pay all or part of their medical bills.

http://www.chcf.org/documents/hospitals/
PriceCheckMysteryHospitalPricing.pdf

Comments: Access to health-care price information theoretically would be important not only for the uninsured (over 6 million in California alone), but also for the insured if price sensitivity of consumer-driven health plans (CDHP) were to have any significant impact on reducing health care spending. This study demonstrates that voluntary efforts and even legislation have not been very effective in informing price-sensitive health-care shoppers of their options.

This report recommends that improvements be made in providing information on pricing, but this conclusion should be challenged on the basis that the framing of the problem was inappropriate.

Sending a patient out on his/her own, with very limited financial resources, to find best prices when options may be limited or nil, is not an effective policy for cost containment. If a patient needs a C-T scan or cardiac catheterization, that patient is really limited to the facilities that his/her physician utilizes if care is to be properly coordinated.

We should be directing our efforts to providing maximum value for beneficial health-care services. A much more effective solution would be to enlist the power of a monopsonistic, single-payer purchaser that would negotiate for all patients not only the best prices, but also the best services and products.

It’s time to give up on bending or breaking the health-care system merely to make it pliable to free-market competition. What is this really all about?
The whims of free-market theorists, or the health of the people?

New Study Shows U.S. Hospital Charges Continue to Rise, Even After Changes in Medicare Payment Policy

California Nurses Association

– EMBARGOED FOR RELEASE –
December 13, 2005

Contact: Charles Idelson, 510-273-2246, 415-559-8991 (pg/cell), or the IHSP at 510-267-0634.

New research on pricing practices of over 4,200 hospitals across the U.S. documents that huge markups in charges to patients are continuing, even after federal changes in Medicare reimbursement policies that were supposed to help contain skyrocketing costs.

The research is contained in the third annual report on charges by the Institute for Health and Socio-Economic Policy (IHSP), the research arm of the California Nurses Association. For the third consecutive year, the report documents a strong correlation between huge hospital markups on their sticker prices over their costs, high profits and the growth of large corporate hospital chains.

What may be most striking in the new report is that charges continue to be scandalously high even after Medicare changed its reimbursement policy following the huge public outcry over outlier payments, made for especially complicated medical procedures.

But, the new report shows, the nation’s 100 most expensive hospitals set their gross charges at an average of 680% (up from 673% in 2002-2003) of their costs– meaning the average top 100 hospitals would bill $680 for a patient’s case where the actual costs were $100, or a 680% charge to cost ratio. The national average for all 4,184 hospitals surveyed was 244% of costs, an increase from 232% the prior year.

Notably, 77% of the hospitals — and 95 of those in the 100 most expensive — had at least one fiscal quarter included in their cost reports after the Medicare changes were announced.

Medicare, noted IHSP director Don DeMoro, adjusted the financial threshold at which outlier payments would kick in, with a resulting decline in reimbursements of $1.8 billion for those hospitals included in this year’s report. “Yet it’s abundantly clear that hospitals, in the aggregate, responded by raising their charges at an increasing social cost. The impact of the Medicare ruling overall appears to be minimal.”

“The result,” said CNA President Deborah Burger, RN, “is that more people than ever are priced out of access to care. High hospital charges are a direct contributor to skyrocketing increases in healthcare costs that result in more people losing healthcare coverage, more employers eliminating benefits or raising co-pays or deductibles, and the ongoing implosion of our health care system.”

Burger noted that since the Medicare ruling went into effect, hospitals have recorded all time record profits, an aggregate $22.6 billion in 2003 and $26.3 billion in 2004, and the number of uninsured has climbed to 46 million. “The system is working for well-heeled execs of the healthcare industry, but not for the rest of us.”

Included in the report is a listing of the nation’s 100 most expensive and 100 least expensive hospitals, the top 10 most expensive hospitals by state, and the 40 hospitals that charge the most for operating room services, prescription drugs, and medical supplies. The research is based on federal cost reports with aggregated data for over 30.5 million patient discharges in fiscal years 2003-2004 filed for all patient services and other financial categories for 4,222 U.S. hospitals.

Among the key findings:

* Higher charges correlate to higher profits.
* Higher charges are also associated with hospital chains, and large hospitals. 89 of the top 100 hospitals were system affiliated, compared to only 30 of the 100 least expensive.
* For-profit hospitals had the highest average charges, 366% of cost, government hospitals the lowest, 181%.
* Hospital markups are much higher for drugs, medical supplies, and operating rooms, which are now primary profit center for hospitals. For drugs, medical supplies, and operating rooms, the top 40 hospitals had respective average charges of 2,319%, 5,090%, and 1,073% of costs.
* High hospital charges are, in part, a result of the hospitals battle with other segments of the healthcare industry, especially pharmaceuticals and HMOs.
* New Jersey, Florida, California, and Pennsylvania are the most expensive places to get sick. New Jersey hospitals charges were an average 415% of costs.

The report contradicts two notable paradigms:

a- Public oversight, or regulation, reputedly reduces profit and harms the public interest. But, the most regulated state, Maryland, for the second year in a row, had the lowest average hospital charges while the number of Maryland hospitals making profits is right at the national average.

b- Mergers supposedly produce greater efficiency for consumers and thus lower costs. However, the efficiencies gained seem to produce higher charges and profits and more marketing, not lower costs.

Hospital industry officials have contended that the charges don’t matter, but:

a- Charges, or the list price, are the starting point for negotiations with HMOs and other insurers, the higher the charge, the higher the eventual payment.

b- Medicare’s “flat” reimbursement rates vary by individual hospital and are influenced by a number of variables, including a federally computed relative weighting system for each DRG. The DRG weights are heavily impacted by the list prices for products or services. Rather than saying Medicare rates are “flat” or “fixed” it would be more accurate to say the rates “float” year by year relative to variables in the reimbursement system, of which gross charges are a main factor.

c- Self-payers, the uninsured, are forced to pay the full list price.

“This report,” said Burger, “reinforces that no amount of market tinkering can resolve the healthcare crisis. All sectors drive up costs, reducing access to care and undermining quality. Only fundamental change, a universal system based on a single standard of care for all, will end this vicious spiral and produce a humane system that works for Americans.”

The political vulnerability of Medicaid

State Plans Medi-Cal Rate Pinch
By Evan Halper
Los Angeles Times
December 13, 2005

Gov. Arnold Schwarzenegger is planning to cut the rates the state pays doctors to treat the poor, a move medical groups warn would result in more Californians losing access to healthcare.

The administration announced in a bulletin mailed to Medi-Cal providers Monday that it planned to temporarily cut reimbursement rates by 5% through 2006. The news comes at a time when the rates already are so low that many doctors refuse to participate in the program.

“We are paying doctors at the lowest rate of any state,” said Dr. Jack Lewin, chief executive of the California Medical Assn. “Half the doctors in this state have dropped out of the program. The rest are staying involved almost as a goodwill service for their communities. This sends the message from the state that these patients are not that important.”

“We recognize that this rate reduction is a hardship to healthcare providers,” said Ken August, a spokesman for the California Department of Health Services. “But California continues to face a deficit.”

Now California is in much better financial shape. Although the state technically continues to run a deficit – it is on track to spend more money next year than it will bring in – an unexpected surplus in receipts in recent months has left state coffers flush with enough cash to balance it out.

http://www.latimes.com/features/health/medicine/la-me-medical13dec13,1,4645251.story?coll=la-health-medicine

And…

House and Senate Still Far Apart on Medicaid Changes
By Robert Pear
New York Times
December 12, 2005

Members of Congress will soon plunge into battle over the future of Medicaid as House and Senate negotiators try to resolve huge differences in legislation that would allow states to cut benefits and increase charges for millions of low-income people, including many children.

In a detailed analysis of the House bill, the Congressional Budget Office predicted that 70,000 to 110,000 people would lose Medicaid coverage for failure to pay premiums.

Democrats, who are generally opposed to the House and Senate budget bills, are excluded from the current negotiations.

http://www.nytimes.com/2005/12/12/politics/12medicaid.html?pagewanted=all

Comment: As a program that funds health care for low-income individuals, Medicaid is a welfare program. The political support for providing aid to people in need has significantly waned. The shift toward the emphasis on individual responsibility began before President Bush took office, as it was President Clinton who set out to “end welfare as we know it.” The issues are much more political than they are partisan.

Low-income individuals lack a forceful political voice. A tax-funded health insurance program designed specifically for them will always be vulnerable to the budget-cutting process. Since adjustments never match the rate of inflation, underfunding is compounded over time.

With increasing financial losses for those caring for Medicaid patients, the number of willing providers declines. Concentrating money-losing patients amongst fewer providers is creating a variation of the death spiral since the increases in losses are not sustainable. As providers withdraw, impairment of access and outcomes is inevitable.

The federal government and the states are not going to search for new revenue sources to pump up the Medicaid budget. Instead, the search is on for benefit reductions that address budget issues rather than health-care needs. The problems of Medicaid will only grow worse. We don’t need more partisanship, but we do need constructive politics to make it happen.

Rather than a welfare program, low-income individuals should be placed in an equitable, universal system of social insurance. Just as our current social insurance program – Medicare – has strong political support, so would a universal, single-payer Medicare for All.

The HDHP and CDHP experiment has already failed

Early Experience With High-Deductible and Consumer-Driven Health Plans:
Findings From the EBRI/ Commonwealth Fund Consumerism in Health Care Survey
By Paul Fronstin, EBRI, and Sara R. Collins, The Commonwealth Fund
Employee Benefit Research Institute
December 2005

This report presents findings from the first EBRI/Commonwealth Fund Consumerism in Health Care Survey. The online survey of privately insured adults ages 21-64 was conducted to provide national data regarding the growth of high-deductible health plans with and without savings accounts and their impact on the behavior and attitudes of health care consumers. The sample was randomly drawn from Harris Poll Online, Harris Interactive’s online sample of Internet users who have agreed to participate in research surveys. The final sample of adults participating in the survey is skewed toward higher-income, more highly educated individuals and also under represents minorities.

Despite its limitations, this is the first national survey of individuals with high-deductible health plans who also have savings accounts (HSAs or HRAs), or so-called consumer-driven health plans (CDHPs), and people with high-deductible health plans who are eligible to contribute to a health savings account but who currently do not have an account (HDHP).

Health Care Spending

When combined with premiums, outlays on health care as a share of income rose substantially among those with HDHPs and CDHPs, particularly among those with low incomes or health problems. More than two-fifths (42 percent) of people with HDHPs and 31 percent of those in CDHPs spent 5 percent or more of their income on out-of-pocket costs and premiums, compared with 12 percent of people in comprehensive plans. Nearly everyone (92 percent) with HDHPs with incomes under $50,000 spent 5 percent or more of their income on out-of-pocket costs and premiums, and one-third spent 10 percent or more. This compares with 34 percent of people in that income group in comprehensive plans who spent 5 percent or more of their income and 10 percent who spent 10 percent or more. People with health problems in HDHPs were also vulnerable to spending large shares of their income on out-of-pocket costs and premiums: more than half (53 percent) of those in HDHPs with health problems spent 5 percent or more and 18 percent spent 10 percent or more.

Cost-Related Access Problems

While people reported using health services at similar rates across health plans, adults with CDHPs and HDHPs were significantly more likely to report that they had avoided, skipped, or delayed health care because of costs than were those with comprehensive insurance, with problems particularly pronounced among those with health problems or incomes under $50,000. The survey asked whether in the last year respondents had delayed or avoided getting health care services when they were sick because of costs. About one-third of people in CDHPs (35 percent) and HDHPs (31 percent) reported delaying or avoiding care, twice the rate of those in comprehensive health plans (17 percent). Having a health problem made it more likely that people avoided or delayed care. Among people who reported being in fair or poor health or having at least one chronic health condition, those in CDHPs or HDHPs reported delaying or avoiding care at higher rates than those in comprehensive plans: 40 percent of those in CDHPs and 31 percent of people in HDHPs, compared with 21 percent in comprehensive plans.

Attitudes and Satisfaction

Overall, individuals with comprehensive health insurance were more satisfied with their health plan than individuals with CDHPs and HDHPs. Specifically, 63 percent of individuals with comprehensive health insurance were extremely or very satisfied with their health plan, compared with 42 percent among CDHP enrollees and 33 percent of individuals with HDHPs.

Availability and Use of Cost and Quality Information

The survey asked respondents whether their health plans provided any information regarding the cost and quality of providers. Just 1 in 7 people (12-16 percent) in all plan types said that their plans provided either type of information on doctors and hospitals.

More than 70 percent of people enrolled in CDHPs and 60 percent of those in HDHPs strongly or somewhat agreed that the terms of their health plans made them consider costs when deciding to see a doctor when sick or fill a prescription; less than 40 percent of those in comprehensive plans felt this way.

Conclusion

At its most fundamental level, consumerism in health care is an attempt to wrest control of the galloping increase in health care costs experienced by employers over the first half of this decade by addressing the incentives surrounding the demand for health care. This survey finds that consumer plans do, in fact, significantly raise consumer sensitivity to costs and reduce use.

But the survey also demonstrates that at least one factor crucial to the success of consumer-driven health plans-realistic, useful, accessible health-cost information-does not yet exist on a widespread basis. Further, the survey also demonstrates that cost-related reductions in demand are highest among individuals with the most to lose-those who are sick and those who have low incomes. To the extent that the health care cost problem is a problem owned by all of us, early evidence from the consumerism movement suggests that solving it through blunt, demand-side instruments like high deductibles gives disproportionate responsibility for the problem to the most vulnerable among us.

http://www.ebri.org/pdf/briefspdf/EBRI_IB_12-2005.pdf

Comment: Although the negative impact of CDHPs and HDHPs were fully predicted and then confirmed by this survey, one finding is shocking in the intensity of the negative impact: “Nearly everyone (92 percent) with HDHPs with incomes under $50,000 spent 5 percent or more of their income on out-of-pocket costs and premiums, and one-third spent 10 percent or more.” The introduction of financial disincentives to care resulted in widespread financial hardship.

A fundamental principle of health care research is that when preliminary results demonstrate significant harm that cannot be offset by any potential benefit, it is an ethical imperative that the study be terminated immediately. The experiment with CDHP and HDHP has already crossed that threshold. Further experimentation can only define more precisely the enormity of financial hardships created. Health policy researchers have the same ethical obligation as biomedical researchers; they should call for an immediate end to this disastrous experiment.

What feature of this model is causing the harm? The HSA plays an insignificant role in that it is merely a restricted savings account. The patient must still meet the out-of-pocket expenses whether they come from other income or savings or from this account distinguished primarily by an inequitable, regressive tax benefit.

The real harm is caused by the high-deductible requirement of both the CDHPs and the HDHPs. Extensive data already exist that confirm the harm done by high deductibles in impairing access and health outcomes and in creating a financial burden for those in need. This study indicates that the financial hardship appears to be far more extensive than previously thought.

What can we do? Existing HSAs can be converted into IRAs, and future HSAs should be prohibited as bad tax policy, bad pension policy and bad health policy. HDHPs should be prohibited. Financial hardship created by the need to access the health-care system can be eliminated by covering all beneficial services through a single risk pool. Since insurers will never attempt to corner the market on those who need care, this can be accomplished only by public policies requiring a universal pool. It’s time for single payer.