The San Diego Union-Tribune
May 22, 2002

By Rodrigo Munoz, a psychiatrist and president of the San Diego County Medical Society

… San Diegans will continue to be on the short end of the stick when it comes to accessing critical mental health services. That is because of the little-known but powerfully disruptive practice called a “carve-out,” which allows insurers to skirt around the laws on mental health parity and deliver the least amount of care for the greatest financial return.

On paper, carve-outs are simple to understand. Insurance industry giant XYZ Health is given the contract to insure the employees of a large corporation, probably by tendering the lowest premium bid. XYZ Health promptly subcontracts with a for-profit company to handle the mental health claims under the insurance policy, severing the mental health benefit from the rest of the policy, usually for as little as 25 cents per member, per month.

If you ask how any company could turn a profit when it is being reimbursed a quarter a month for each member of the insurance plan that might seek treatment, you’re onto something. The only way that these firms (called “behavioral health companies” in industry jargon) can make money is by making it virtually impossible for those in need to get treatment.

These companies make it hard for people to see a psychiatrist in the first place, limit the number of times a patient can see a psychiatrist, limit the amount of time they will pay for the psychiatrist to see the patient to 20 minutes and force people out of the hospital before they can safely go home, with no adequate follow-up provided. This is a clear violation of the mental health parity law, but they get away with it, because the benefit has been “carved out.”

The saddest thing is that many patients and even the employers who pay the bill don’t realize that the HMO they have entrusted with their business and their health has washed its hands of a piece of it. They only find out that XZY Health is out of the picture when they go to access treatment, unsuccessfully.

Treatment for disorders of the brain should not be carved out and away from the insurance benefit any more than diseases of the kidneys, eyes or heart. “Separate but equal” is no more tolerable in health care than it was in public education. Unless we end the practice, we will have to substitute the word “parody” for “parity” when discussing mental health treatment in San Diego.

http://www.signonsandiego.com/news/uniontrib/wed/opinion/news_mz1e22health.html

Los Angeles Times
May 23, 2002
By Nicholas Riccardi and Garrett Therolf

Under the most optimistic plan, the county would have to close the emergency room at Harbor-UCLA Medical Center near Torrance, eliminate trauma services at King/Drew….

The deficit stems largely from the fact that the county health system treats many of the nearly 3 million uninsured patients in Los Angeles County. Over the years, the county has lost funding while the number of uninsured people has grown.

Dr. Brian Johnston, past president of the Los Angeles County Medical Assn.and an emergency room physician:

“They should put out a public announcement in some of these communities that if something bad happens to you, you are on your own. That’s a very busy trauma center. What’s going to happen to those people?”

http://www.latimes.com/news/printedition/front/la-052302health.story?coll=la%2Dhome%2Dtodays%2Dtimes

Comment: Most Americans are concerned about the problems of the uninsured. They do believe that measures should be taken to assure access to care for everyone. But they are uncomfortable about increasing taxes to pay for public programs for the medically indigent. And those that have health care coverage and comfortable incomes have even greater concerns about proposals to replace their health plans with some type of government program. For these reasons there is very little pressure on legislators to seriously address the problems of the uninsured and under-insured. Most would prefer to keep their current secure status in health care even though they regret the problems of the less fortunate.

But how secure is the current status of the affluent? What does it mean to shut down trauma centers? The Institute of Medicine report released this week revealed that an uninsured auto accident victim is more likely to die than a patient with insurance, even though they both were transported to emergency facilities. If merely the insured status makes a difference, then what would be the impact of shutting down the trauma center? Obviously, they are both at much greater risk of dying if they have to be transferred to an over-crowded facility on the other side of a heavily congested city. The affluent may be relatively complacent, but they shouldn’t be.

Currently in California there are proposals to increase funding of trauma care systems by tax increases. But Gov. Davis’ office responded that it is unlikely that the tax increase proposals would receive enough support from the state legislature to pass. Even if they did pass, would this small patch in the gigantic voids in our system really bring us health security?

The $1.5 trillion that we are already spending is enough to fund all care for everyone, but we lack an efficient system to properly direct those funds. The solution is simple. Enact National Health Insurance now.

Institute of Medicine
National Academy Press
May 21, 2002

“… the overall mortality risk for uninsured adults, estimated here to be on the order of 18,000 excess deaths among uninsured adults annually, is comprised of elevated mortality rates across many disease categories. All of these excess deaths among uninsured adults occur among relatively young Americans, those under the age of 65.”

http://books.nap.edu/books/0309083435/html/index.html

Comment: Headline news:

18,000 YOUNG ADULTS KILLED

You didn’t see this headline? Of course not. That’s merely the number of young adults that die each year because they don’t have health insurance. And besides, if we emphasized this tragedy, we would probably have to report the follow-up stories that demonstrate that these young adults (and everyone else) could have had life-saving insurance at no net additional cost to us. We won’t publish those stories. Instead, bland stories on the policy issues of the Institute of Medicine are the order of the day (not to mention that the media wouldn’t want to risk losing advertising revenue from the private health plans). Then the administration wouldn’t be pressured to renew its protest that it’s un-American to have the government interfere with the health insurance marketplace. And we won’t have to see our administration’s typical rhetoric that “18,000 young Americans gave their lives for a free America, protecting the principles that make America the great nation that it is.”

Since 9/11, our government is turning the world upside down because of the tragic loss of life that day. Yet just since 9/11, FOUR TIMES AS MANY YOUNG ADULTS HAVE DIED because of the lack of insurance. Each two months of inaction duplicates the loss of that tragic day. And our government remains silent. Our leaders won’t even discuss real solutions because, “We don’t want ‘the government’ involved in our health insurance.”

Why does America tolerate this rhetoric? It’s sick! Our health care system is sick! And our political leaders are doing nothing to cure the problems!

It’s time to grab the placards and take to the streets! Let’s go!

AARP May 21, 2002

“More people age 50 to 64 are uninsured today than in the past. Individuals who are accustomed to feeling secure about their health coverage are increasingly at risk of not having needed protection. Medicare beneficiaries are frequently without adequate coverage, especially for prescription drugs. Vulnerable subgroups of people age 50 and older continue to experience problems in accessing health care services.”

Implications for Policy (Paraphrased and abridged)

1. Consider socioeconomic conditions in addition to clinical conditions.

2. Expand not just life but also health.

3. Use the public health system to alter the impact of individual behavior and personal choices on health and disability.

4. Address the lack of long-term coverage and the inadequacy and instability of health care coverage for those over 50.

5. Make better use of resources.

6. Improve the quality of health and long-term care systems.

7. Develop a national health information infrastructure.

http://www.aarp.org/beyond50/

Comment: This new report from AARP describes many of the problems with our health care system, especially the impact on those over age 50. There are no surprises in this report. Particularly, AARP has once again failed to surprise us in that they are adhering to their policy position that “good health is better.”

Although AARP does not wish to offend its large and politically diverse membership base, that does not mean that it cannot lay before us health care policy which would seriously address the problems described. A universal, publicly administered, national health insurance program, with appropriate support of the public health system, would correct the problems without significantly increasing global health care costs. The California Health Care Options Project demonstrated that Medicare beneficiaries (and indeed everyone), under the universal models, would receive greatly expanded benefi ts while virtually eliminating financial barriers to care, and global health care costs actually would be reduced.

Is AARP so intimidated by its conservative members that maintaining silence on reform that reflects progressive thought has priority over an open and frank discussion of real solutions to our problems? The AARP membership must become informed on the options. The spectrum from progressive to conservative positions can be presented, but decisions need to be made by an informed public. AARP can provide the leadership in this process. Or is it really better to continue the politically safe approach of remaining silent on the truth and continuing with the very sick status quo?

May 2002
“Sicker and Poorer: The Consequences of Being Uninsured” By Jack Hadley, Ph.D., Principal Research Associate, The Urban Institute

… this report focuses primarily on the relationship between health insurance and health outcomes, which has been addressed by a surprisingly large number of studies over the past 25 years, as well as the link between health and educational attainment and economic opportunity.

This review shows that there is a substantial body of research consistent with a model postulating positive relationships between health insurance, use of medical care, health, income, and education. However, as noted at the outset, none of these studies is definitive, nor are their findings universal. The literature also includes studies that have failed to find a positive relationship between good health and having health insurance or using more medical care.

While all of these studies suffer from methodological flaws of varying degrees, two general observations appear warranted. The first is the fairly remarkable degree of consistency across the studies that support the underlying conceptual model of the relationship between health insurance and health. Studies of different medical conditions, conducted at different times, using different data sets and statistical methods have produced quantitative estimates of the effects of having health insurance or using more medical care that are both consistent with each other and fall within a relatively narrow range. This degree of quantitative agreement across studies reinforces the implications of any single study taken by itself.

The second general observation, holding aside issues of potential methodological weaknesses, is that many of the studies that failed to find a positive association between health insurance or medical care use and health do not obviously generalize to the current population of uninsured nonelderly adults and their families. Casual empirical observations of pre-Medicare/Medicaid data in the U.S., studies of inefficient medical care use by the elderly or privately insured, and studies of birth outcomes may not be directly relevant to assessing the health benefits of extending health insurance to those who are currently without insurance coverage. Even if one accepts as valid the findings of the more methodologically sound studies that suggest little or no health benefit from additional medical care use by well-insured populations, it does not necessarily follow that the uninsured would not benefit both from health insurance coverage and from greater medical care use. Holding both points of view would not be inconsistent. In fact, it would seem to be both inappropriate and unfair to argue on the basis of these studies that the uninsured should be penalized, i.e., denied help in obtaining insurance coverage, because of the inefficient or excessive use of medical care by the well insured.

This report concludes that a compelling case has been made that having health insurance does lead to improved health by means of better access to medical care. Furthermore, the available research on the links between health insurance, health status, and an individual’s productivity begins to provide a reasonable basis for future economic analyses of the benefits of health insurance to the nation as a whole.

The next step for health services research is to estimate the size of the economic benefits of continuous health coverage. Estimates of the size of the potential economic benefits should become a prominent part of policy debates over expanding health insurance coverage. These estimates may help shift the current focus from the direct costs of health insurance expansions to the question of how much is likely to be saved by expanding coverage, and ultimately to policy decisions based on a truer sense of the net cost to the nation to cover all Americans.

(The comments above include excerpts from the Executive Summary and excerpts from the Full Report that have been commingled .)

http://www.kff.org/content/2002/20020510/

Comment: This comprehensive review of the extensive research on the consequences of being uninsured is a very valuable resource that confirms that the lack of insurance has major negative impacts. This report can be used to refute the arguments of those that use isolated studies to suggest that the uninsured do receive the care that they really need. They clearly do not.

The White House
May 17, 2002

President George W. Bush:

… the myth is somehow that if seniors are given choice, low income seniors will not benefit; that if we provide more options for our senior citizens to tailor plans that meet their needs, that somehow the low income will be left behind.

Part of my message today is I want to work with you to provide more choices and more savings for our seniors. (Applause.) I’m a person who trusts people. See, I trust the American people. The American people are fantastic, great citizens. We’ve got to trust people with their own choices in life. I’d rather have the American people make choices than the federal government make choices on their behalf. (Applause.)

We need a fair system of competition. We need a system that guarantees that patient protections and all of Medicare’s required benefits are included in every choice; a system that encourages additional benefits and options for better care at lower cost, including improved medical savings accounts.

That’s what we need to think about, and that’s where we ought to head here in America. The costs savings from competitive reforms are essential. They’re essential. If you notice, and the people will testify to this, that there are lower costs in Medicare plus Choice. And those cost savings in a Medicare plus Choice plan are very important for the future, for your children and your grandchildren to be able to have a Medicare system that works.

http://www.whitehouse.gov/news/releases/2002/05/20020517-8.html

Comment:

President Bush has used “lower costs” in two contexts.

Many participants in the Medicare plus Choice plans have had lower out-of-pocket expenses and more benefits than available in the traditional Medicare program. This results in a “lower cost” for the individual Medicare plus Choice beneficiary. This has been possible because the Medicare plus Choice plans have been practicing virtuous selection by marketing their plans specifically to the healthy, thereby avoiding higher costs of chronically ill patients.

On the other hand, studies have confirmed that the Medicare plus Choice plans have higher costs per beneficiary than for comparable beneficiaries in the traditional Medicare program, primarily because of higher administrative costs. Competition of Medicare plus Choice options not only failed to reduce costs but actually failed to prevent increases in costs. This is an irrefutable fact. But when President Bush says, “The cost savings from competitive reforms are essential,” and “… a fair system of competition… a system that encourages additional benefits and options for better care at lower cost,” he is using “lower cost” in the context that the private plan options will reduce costs for the Medicare program. That is simply not true.

Since the private plans will always have higher administrative costs than the publicly administered program, the only ways to reduce costs for the program are to restrict benefits and/or to increase patient cost-sharing. Thus, President Bush’s version of Medicare modernization will allow options that provide only minimal benefits or higher out-of-pocket expenses or a combination thereof. If Medicare beneficiaries want more coverage, they will have to pay higher premiums. What will happen to low income seniors? They will have impaired access because of financial barriers erected under his proposal. And yet, President Bush states that it is a “myth… that somehow the low income will be left behind,” when given “more options to tailor plans.” The only options affordable will leave low income individuals behind.

We need to understand the problems with our health care system and the effect that various policy decisions would have on access, equity and costs. President Bush should lead the quest for the truth by dismissing his health care ideologues and bringing in serious health policy analysts that will provide an objective assessment of all options for reform. He trusts us. He trusts us with our choices. He’d rather have the American people make choices than have the federal government make choices on their behalf. He should trust us to tell him what choice we want in health care reform once we have an honest presentation of all of our potential options.

Health Affairs
May/June 2002

Surprisingly few Canadians travel to the United States for health care, despite the persistence of the myth.

by Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer, and Robert G. Evans

A tip without an iceberg?

This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross- border flow of care-seeking patients appears to be very small.

Our telephone survey of likely U.S. providers of wait-listed services such as advanced imaging and eye procedures strongly suggested that very few Canadians sought care for these services south of the border. Relative to the large volume of these procedures provided to Canadians within adjacent provinces, the numbers are almost undetectable. Hospital administrative data from states bordering Canadian population centers reinforce this picture. State inpatient discharge data show that most Canadian admissions to these hospitals were unrelated to waiting time or to leading-edge-technology scenarios commonly associated with cross- border care-seeking arguments. The vast majority of services provided to Canadians were emergency or urgent care, presumably coincidental with travel to the United States for other purposes. They were clearly unrelated either to advanced technologies or to waiting times north of the border. This is consistent with the findings from our previous study in Ontario of provincial plan records of reimbursement for out-of-country use of care. Additional findings from the current study showed that a small amount of cross-border use was related to proximal services, primarily in rural or remote areas where provincial payers have made arrangements to reimburse nearby U.S. providers. Finally, information from a sample of “America’s Best Hospitals” revealed very few Canadians being seen for the magnet referral services they provide.

These findings from U.S. data are supported by responses to a large population-based health survey, the NPHS, in Canada undertaken during our study period (1996). As noted above, 0.5 percent of respondents indicated that they had received health care in the United States in the prior year, but only 0.11 percent (20 of 18,000 respondents) said that they had gone there for the purpose of obtaining any type of health care, whether or not covered by the public plans.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”-ideas that, on logic or evidence, are intellectually dead-that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://www.healthaffairs.org/freecontent/v21n3/s6.htm

Comment: This excellent study refutes the false generalizations that have been extrapolated from the embellished anecdotes of Canadian medical refugees in the United States. Debates on health care policy should be based on the best factual information available regardless of whether or not those facts support individual ideological viewpoints. This important study should be downloaded and made readily available to refute those that insist that single payer approaches should be dismissed immediately without further consideration merely because of the fictional massive medical migration from Canada into the United States.

Health Affairs
May/June 2002

Surprisingly few Canadians travel to the United States for health care, despite the persistence of the myth.

by Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer, and Robert G. Evans

A tip without an iceberg?

This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross- border flow of care-seeking patients appears to be very small.

Our telephone survey of likely U.S. providers of wait-listed services such as advanced imaging and eye procedures strongly suggested that very few Canadians sought care for these services south of the border. Relative to the large volume of these procedures provided to Canadians within adjacent provinces, the numbers are almost undetectable. Hospital administrative data from states bordering Canadian population centers reinforce this picture. State inpatient discharge data show that most Canadian admissions to these hospitals were unrelated to waiting time or to leading-edge-technology scenarios commonly associated with cross- border care-seeking arguments. The vast majority of services provided to Canadians were emergency or urgent care, presumably coincidental with travel to the United States for other purposes. They were clearly unrelated either to advanced technologies or to waiting times north of the border. This is consistent with the findings from our previous study in Ontario of provincial plan records of reimbursement for out-of-country use of care. Additional findings from the current study showed that a small amount of cross-border use was related to proximal services, primarily in rural or remote areas where provincial payers have made arrangements to reimburse nearby U.S. providers. Finally, information from a sample of “America’s Best Hospitals” revealed very few Canadians being seen for the magnet referral services they provide.

These findings from U.S. data are supported by responses to a large population-based health survey, the NPHS, in Canada undertaken during our study period (1996). As noted above, 0.5 percent of respondents indicated that they had received health care in the United States in the prior year, but only 0.11 percent (20 of 18,000 respondents) said that they had gone there for the purpose of obtaining any type of health care, whether or not covered by the public plans.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”-ideas that, on logic or evidence, are intellectually dead-that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://www.healthaffairs.org/freecontent/v21n3/s6.htm

Comment: This excellent study refutes the false generalizations that have been extrapolated from the embellished anecdotes of Canadian medical refugees in the United States. Debates on health care policy should be based on the best factual information available regardless of whether or not those facts support individual ideological viewpoints. This important study should be downloaded and made readily available to refute those that insist that single payer approaches should be dismissed immediately without further consideration merely because of the fictional massive medical migration from Canada into the United States.

May 17, 2002

Bill Moyers: I don’t know if your reporting has turned this up, the answer to this question, but every industrialized democracy in the West, and some developing countries, treat health care as a human right. We treat it as a function of the market. Why can’t we move toward what so many others embrace?

Julie Rovner (NPR’s health policy correspondent): I think because we’ve had this ongoing debate really over the last 50 years about which way to go. Everybody agrees that people should have health insurance, that people should be able to have access to health care, to good coverage. But we can’t resolve this, every other country managed to resolve this, most of them years ago, some of them more recently. But there is this continuing standoff, a policy standoff in Washington, to some extent in the states, too; you’ve really got people dug in on whether to get the government more out of health care or whether to get the government more into health care.

http://www.pbs.org/now/transcript/transcript_rovner.html

Comment:

Government: The act or process of governing, especially the control and administration of public policy in a political unit. (The American Heritage Dictionary of the English Language)

All nations, including the United States, utilize governments to administer health care policy. As Julie Rovner states, “Everybody agrees that people should have health insurance, that people should be able to have access to health care, to good coverage.” Since we agree on this, and we know that this goal is absolutely impossible to attain in the private sector, why aren’t we taking advantage of our ability to establish the public policy we want by utilizing our own government that belongs to all of us?

Government is not a “they,” it’s a “we.”

American Medical News
May 20, 2002
Richard F. Corlin, MD

“… Congress should change current rules that require physicians to participate in Medicare on an ‘all-or-nothing basis,’ regardless of our patients’ income or wealth. Physicians should have the freedom to decide, on a patient-by-patient basis, whether services are rendered under a ‘private contract’ or subject to Medicare payment limits.”

http://www.ama-assn.org/sci-pubs/amnews/amn_02/edca0520.htm

Comment: The experience in other nations has documented that parallel private and public plans result in chronic under-funding of the public program with the development of queues. Physicians then cater to the more lucrative private patients who are able to purchase their place at the front of the queue, and they neglect the patients in the public program, causing the queues to grow longer.

For over a century, conservatives have maintained a lock on the leadership of the American Medical Association. Efforts to establish objectivity in policy discussions have been repeatedly rebuffed by those in control. Perhaps this is why the AMA membership has declined from 85% to 28% in the past few decades.

The accelerating deterioration in access, coverage and costs mandates reform now. The AMA’s pious pomposity has resulted in the egregious neglect of reform that is in the interests of patients. The majority of physicians do support reform that would assure comprehensive care for everyone.

Physicians for a National Health Program is a single issue organization that advocates for a universal, comprehensive national health care program. All physicians should study the policy proposals on the PNHP website (www.pnhp.org) and the AMA website (www.ama-assn.org). It is clear that the AMA policies would compound inequities and further impair access, whereas PNHP policies would assure comprehensive services for everyone. Those physicians that really care should join PNHP and encourage their colleagues to do so as well. A strong, united voice of concerned and caring physicians can ignite the flame of reform.

For those that do care but are not yet members, go to www.pnhp.org and click on “Join PNHP.” Do it now.

Beth Capell, Ph.D., on AMA President Corlin’s comment on allowing “private contracts” for Medicare:

Great to see that the AMA still opposes Medicare after all these years!! One of the greatest boons to physician incomes as well as essential for seniors and AMA opposes it.

Actually, Corlin does not propose queuing: he proposes being allowed to ignore the low and moderate income Medicare patients entirely. That’s worse.

Beth Capell, on behalf of Health Access.

Comment: In sharp contrast to the AMA, Physicians for a National Health Program supports “Better than Medicare” for our seniors and for everyone in our nation. PNHP supports changes that would include all beneficial services, including prescription drugs, long term care, mental health services, dental, and eye care, while assuring affordability by eliminating out-of-pocket expenses. The California HCOP study and other studies confirm that this can be done without increasing overall health care costs.

Strengthen the voice of PNHP. Join today.

www.pnhp.org and click on “Join PNHP”

May 15 is National Medicare Day across Canada

Ottawa – The National Union of Public and General Employees and its components will join with thousands of Canadians today on National Medicare Day, participating in a variety of nation-wide activities to demonstrate support for public medicare and to celebrate the best health care plan in the world.

May 15 has been designated National Medicare Day across the country.

NUPGE members will be marking the day by holding workplace canvasses, rallies outside hospitals and politicians’ offices and town hall meetings. They will also be distributing post cards and encircling provincial legislatures in red ribbon.

The theme of the day – A Call to Care: Patients not Profits – reflects the growing awareness that the spread of private for-profit health care threatens patients and will destroy our public medicare.

It’s been 40 years since Canada rejected for-profit health care and created no-profit medicare for everyone. The insurance companies and medical corporations still can’t believe it. They still work hard at trying to shake our faith our medicare.

They can’t. And they won’t. Not so long as we remember how it is when health care becomes a cash-and-carry, for-profit enterprise: care is expensive, inadequate and inequitable. Any hope of full care without financial ruin depends on whether or not you are covered by a private plan. Even then there are no guarantees.

When private for-profit insurance companies have to choose between their wealth and their health, we lose every time. Canadian-style medicare eliminates ever being faced with that choice.

Medicare is all ours. We made it. We like it. We want to keep it.

That’s something to celebrate.

http://www.nupge.ca/news_my02/n15my02a.htm