The Washington Post
February 19, 2002
By Abigail Trafford

“With pomp and circumstance and the glare of TV lights, representatives from 12 leading health, business and labor organizations signed a proclamation to ‘come together from diverse perspectives to seek solutions to one of America’s greatest problems.'”

“But the marching spirit of the summit conference started to sputter as soon as the health care moguls were asked about solutions. Out came the old buzzwords of stall, stall and stall: ‘Incremental,’ said one chieftain. There would be no one solution but a number of possible steps to chip away at the problem. ‘Public, private, incremental, long haul,’ agreed another. ‘Progress will be slow,’ said the consumer representative. ‘We have to keep the best we have and allocate resources,’ added another leader. ‘Incremental,’ echoed another.”

“To find solutions, each leader at the summit has to be willing to lose a little for the country to gain a lot. ‘Incremental’ is not a word that helps Potter, Hegdal or Henderson (examples of the plague of ‘uninsurance’). They’re not interested in ‘slow progress.’ They need coverage now. The uninsured have been waiting for decades for some relief.”

“So let’s give the chieftains 90 days to come up with a unified plan. After that, to return to the civil rights mode, it may be time for a march on Washington.”

http://www.washingtonpost.com/wp-dyn/articles/A18970-2002Feb15.html

Hundreds of thousands of Americans watched this weekend as a desperate father held a hospital emergency room at gunpoint and demanded a heart transplant for his dying son. Fortunately for everyone, it all happened in a movie, ‘John Q,’ which opened Friday

Los Angeles Times
February 18, 2002
‘John Q.’s’ Public Warning By Benedict Carey

Hillel Laks, M.D., Professor and Chief, Division of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles:

“It’s very important for people to know what their insurance pays for, and to know they can do something about it. John Q. could have gone to the company and said, ‘I don’t like this policy. I want to spend $100 more and get better insurance.’ If he’s willing to go shoot people to save his son, why can’t he pay a little extra a month to make sure he’s covered?”

http://www.latimes.com/features/health/la-000012439feb18.story?coll=la%2Dheadlines%2Dhealth

Comment: Professor Laks is a noted and respected expert on heart transplants. However, before he ventures further into expressing public opinions on health policy, I would emphatically recommend that he become more versed in the basic fundamentals of this discipline. He might begin by reading “Understanding Health Policy” by Thomas Bodenheimer and Kevin Grumbach.

Importunely, Dr. Laks’ response represents the prevailing view of the leadership of the medical associations, of many business leaders, and the conservatives and many moderates who now control the political agenda. Their rhetoric is that control of health care should be shifted to the consumer, and this is done by defining the contribution of either the employer or the government and then allowing the beneficiary-patient to have “choice” of the type of coverage by contributing the balance of the premium. That “choice” for those with very limited income and assets, such as John Q and another 100,000,000 or so in the United States, either requires an often unaffordable premium, or requires that the individual select options with unaffordable out-of-pocket expenses. For the benefit of Dr. Laks and others that don’t seem to quite get it, in health policy terms, this is called “defined contribution” and “shifting risk to the beneficiary.”

In fact, everyone who is going to take a stand on issues of health policy should read “Understanding Health Policy.” If individuals are going to support cruel and inhumane health policies, they should understand exactly what they are doing. In this age, they should not be allowed the intellectual laziness and the “Let them eat cake” insensitivity of proclaiming, “Let them have choice,” and then walking away from the problem.

Understanding Health Policy: http://shop.mcgraw-hill.com/cgi-bin/pbg/0071378154.html?id=aaHGHsD3

Kip Sullivan, responding to the Wennberg et al proposal for Medicare reform:

I agree with your statement that Wennberg et al. have presented a compelling argument that Americans are exposed too often to overuse and underuse of medical services. And I agree as well that Wennberg is wrong to promote HMOs as the mechanism best suited to reduce overuse and underuse. However, I want to call attention to a proposal Wennberg makes that you didn’t discuss which I believe is dangerous and doomed to fail.

Wennberg, like all managed-care advocates, believes quality (overuse, underuse, and misuse) can only be improved if the structure of the health-care system is changed, and if patient privacy is destroyed (or, at best, placed at grave risk). Wennberg shares two beliefs with Paul Ellwood and other managed-care advocates: (1) quality cannot be improved unless doctors are herded into large entities — preferably HMOs — that have enough power over doctors to force, cajole, and/or educate them into changing their practice style, and (2) patient medical files are dumped into large information depots, preferably national depots, and these depots are used by researchers to determine “best practice.” Both beliefs, casually and frequently expressed by the managed-care crowd, have never been elaborated, and certainly never proven. I think both beliefs are nonsense. A thorough refutation of this nonsense would take up more time than I have today. I comment on just two issues.

The notion that doctors can improve their understanding of the massive medical-science literature only if they leave solo practices and join large networks of docs or HMOs makes several bogus assumptions, the most important of which is that the bureaucrats who head up the network or HMO do have plenty of time to keep up with the medical literature, and, given their superior knowledge and their managed-care tools (utilization review, financial incentives, etc.), are capable of forcing or inducing the army of doctors under their command to weed out the “bad practices” and nourish the “best practices.” Just saying this seems to me proof enough of the silliness of this proposal, but if there are people on this list who would like to question this statement, please do. This is a complex issue and I’d be happy to expound.

The second premise I want to quarrel with is Wennberg’s assumption that medical research has been shackled, lo these many centuries, by the absence of national or regional information depots containing all information on all patients. (To my knowledge, Paul Ellwood was the first person to make a big splash promoting this nonsense. He did so in a 1988 article for the New England J Med.) The problems with this proposal are numerous and mind-boggling.

The most serious problem with the notion that advances in medical science depend on researchers trolling through millions of patient files is that it pretends, without saying so, that the historic methods of advancing medical science were never any good, or were terribly inefficient. The gold standard in scientific research is, of course, the prospective, controlled trial. Trolling through patient files after patients have received medical care is, by definition, a retrospective methodology. You can do your best to control for variables that could affect outcomes, but as a rule you’ll never control for all relevant variables with a retrospective methodology as well as you will with a prospective methodology. I’m not saying retrospective research is useless. I’m merely calling attention to an obvious fact — medical science, excuse me, “identification of best practices” will advance faster if we rely primarily on prospective methods, and that increasing the number of retrospective studies based on huge information depots (as opposed to the old-fashioned technique of asking a sample of patients for consent and then reviewing their files) will accomplish relatively little. To put it another way, if we never create gigantic information depots, medical science will continue to advance by the same route it always has — by basic research, by randomized (prospectively designed) clinical trials, by retrospective research using relatively small patients samples, by clinical experience, and by serendipity.

Note the advantage to patients in the old-fashioned methods of advancing medical science — our records are used with our consent. Under the Wennberg proposal, all records (not just that portion relevant to the study) on all patients (not just a sample of patients) are routinely dumped into the depot and kept there till the end of time (which is a much longer violation of patient privacy than the period of time required by the typical old-fashioned prospective or retrospective study).

And I haven’t even discussed the cost of the Wennberg-Ellwood boondoggle.

I think single-payer advocates should state clearly that one of the advantages of a single-payer system is that patient privacy will not be destroyed. To make that promise, we have to reject the HMO advocates’ claim that quality of care can only be maintained or improved if patient files are routinely inspected by researchers. We should instead promote much more old-fashioned research, and more education of doctors and patients about the results of that research.

Urban Institute
By John Holahan and Brenda Spillman

“The weakness of the safety net does not appear to worsen the uninsureds’ access to care. Conversely, a relatively strong safety net does not appear to improve their position relative to the insured. No matter how the uninsured are supported-whether by third-party payers, the presence of community health centers, a high level of disproportionate share payments, or local government subsidies-we find no evidence that these efforts have the ability to eliminate, or even narrow, barriers to access to the extent that insurance can.”

http://newfederalism.urban.org/html/series_b/b42/b42.html

Comment: The Bush administration is touting proposals for expansion of health insurance coverage, such as very modest tax credits, that will have little impact on decreasing the numbers of uninsured. Instead, their emphasis has been shifted to supporting the health care safety-net through programs such as increased funding for community clinics. (Even the seriousness of this commitment can be questioned in light of the 33% reduction in funding resulting from the elimination of the Medicaid upper payment limit for safety-net institutions.)

This study challenges the assumption that strengthening the safety-net system will provide a substitute for the lack of insurance coverage. The relative strength of the safety-net does not alter access to care. In sharp contrast, insurance coverage, or the lack thereof, dramatically impacts access to health care.

Although this study demonstrated that weaknesses in safety-net systems can be compensated for by the remainder of the health care community, it is important to note that there may be an as yet unidentified threshold at which safety-net systems can collapse resulting in further impairment of access for the uninsured. So it is important to maintain the integrity of the safety-net system until we finally resolve the deficiencies in our methods of funding health care.

But the bottom line is that we must make every effort to provide comprehensive health care insurance for everyone. We now know that the only way that we can do this equitably, and still afford to pay for it, is through a single payer system. Let’s start the planning process today!

Health Affairs
Web Exclusive
February 13, 2002

“A reform proposal that addresses some underlying causes of Medicare funding woes: geographic variation and lack of incentive for efficient medical practices.”

by John E. Wennberg, Elliott S. Fisher, and Jonathan S. Skinner

ABSTRACT:

Medicare spending varies more than twofold among regions, and the variations persist even after differences in health are corrected for. Higher levels of Medicare spending are due largely to increased use of “supply-sensitive” services – physician visits, specialist consultations, and hospitalizations, particularly for those with chronic illnesses or in their last six months of life. Also, higher spending does not result in more effective care, elevated rates of elective surgery, or better health outcomes. To improve the quality and efficiency of care, we propose a new approach to Medicare reform based on the principles of shared decision making and the promotion of centers of medical excellence. We suggest that our proposal be tested in a major demonstration project.

http://www.healthaffairs.org/WebExclusives/Wennberg_Web_Excl_021302.htm

Comment: John Wennberg and his colleagues have previously provided more than ample data to confirm that for even those who have access to care and can afford it, Americans are receiving poor value for their health care dollar. Many services are of no benefit and may be detrimental, and other beneficial services are not being delivered. Mediocrity in care is not limited to low-income, uninsured and under-insured individuals, but it is a characteristic of our entire health care system, with some exceptions.

In this report, Professor Wennberg and colleagues demonstrate that doubling spending in Medicare does not result in more effective care nor better health outcomes. They do demonstrate that this increase in spending merely results in increased use of hospitals, intensive care units, and, especially, medical specialist services, but with no improvement in the index of effective care. Clearly, efforts must be made to reform not just Medicare, but our entire health care system.

Professor Wennberg’s group proposes a fresh approach to Medicare reform including promotion of effective care and patient safety, reducing unwarranted variation in preference-sensitive care, reducing overuse of supply-sensitive care, refining monitoring systems, and rewarding more efficient resource use. They mention how this can be studied and implemented quite readily within the Medicare program. In fact, after reading their proposal and giving it some thought, it is clear that a single payer system would form the ideal infrastructure for implementation of these measures that would improve quality and efficiency.

They briefly mention the inequities that might result from implementation of a budget cap, but even those inequities would be more readily addressed through a single payer model than they would through a fragmented system of multiple payers. They also suggest that the Breaux-Thomas model might have a place in competitive strategies, although cooperative strategies should also be considered. However, integrated health systems are the entities that would be competing based on best-practice models, and the business-model health plans characteristic of the B-T proposal would add administrative waste and change the focus from best practices to dollar-flow management. Thus there is no reason to blindly follow the path of incrementalism merely because the authors state that it is more likely in the near future.

This article must be read by everyone who wishes to help improve our health care system. Professor Wennberg, et al, have indicated the direction for reform. It is our task to demonstrate that the single payer model provides the ideal infrastructure for implementing their proposals.

Jonathon Ross, MD, MPH, past president of Physicians for a National Health Program:

Have you seen the ads or the trailer for the movie John Q? Denzel Washington plays a man whose son needs a transplant and ends up going postal when he is told that it is not a covered benefit. I was at the movies when the trailer played.

The trailer finishes with DW holding a hostage and a negotiator saying to him, “How is this going to end, John?”

I couldn’t help saying out loud at the end of these words at the end of the trailer, “National Health Insurance!”

And the audience of about 100 broke into cheers.

Comment: “John Q” opens at theaters today. It has already provoked considerable discussion. Today’s reviews by movie critics are a mix. Some criticize it for using stereotyped characters with predictable behavior. Some criticize dramatizing the use of a violent response (using a gun to take hostages) for a very serious social issue (our failed system of paying for health care). But others clearly acknowledge that the message is very real, that the crisis in insurance coverage today literally threatens lives (though normally much more subtly than in this portrayal).

Discussion of this film has moved from the entertainment section to the news section of the media. And it is the message of the insurance crisis that is being discussed. The anticipated impact is great enough that the American Association of Health Plans is conducting an advertising campaign to deflect the blame to others.

While we need to be sensitive to the fact that violence is used to represent the intensity of the desperation of this fictional father, nevertheless, the nation will be discussing this film and the insurance crisis it portrays. We need to be there to show them that we do have a solution: comprehensive care for everyone with no increase in costs, through single payer health care reform.

For those that have the QuickTime 5 program, the John Q trailer can be viewed at: http://www.apple.com/trailers/newline/john_q.html

Although some may object to specifying single payer reform as the answer, remember that the preliminary results of the California Health Care Options Project demonstrate that only single payer or health service models will provide truly comprehensive care for absolutely everyone, and that they actually reduce health care costs, whereas the incremental models studied fail the tests of universality and comprehensiveness and actually increase health care costs. It is time to refute and chastise those that say that we should stifle the talk of single payer because of political expediency. Single payer is the moral imperative in health care reform. We need to agree on that and then move on with reform.

The New York Times
February 14, 2002
By Milt Freudenheim

“Elderly and disabled members of Medicare H.M.O.’s used nearly 50 percent more of their own money on average for medical care in 2001 than they did three years ago, health care researchers said yesterday.”

“Out-of-pocket costs rose 62 percent to $3,578 in 2001 for people in poor health as their share of spending rose for prescription drugs, premiums and other services not fully covered by Medicare.”

Marilyn Moon, a Medicare policy expert at the Urban Institute:

“Many people joined H.M.O.’s to try to reduce out-of-pocket expenses. The bargain was, ‘we will give up some of our control over medical services in order to have some of our costs reduced.'”

John Rother, legislative and policy director of AARP:

“No one is looking at H.M.O.’s any longer as a way of saving money for Medicare. The reality is, fixing these problems is going to cost some money.”

http://www.nytimes.com/2002/02/14/health/14CARE.html

Comment: The Medicare+Choice options were able to offer pharmaceutical coverage and lower out-of-pocket expenses primarily because of their success at enrolling relatively healthy patients. For several reasons, they no longer have the margins that will allow this largess.

The administration and some members of Congress now want to increase funding for these private sector plans which would allow them to continue to offer richer benefit packages. But these plans are not available to everyone, and they vary in their generosity. Why should those that remain in the traditional Medicare program be denied benefits that the private plans provide? They shouldn’t. They should have the same pharmaceutical coverage and reduced out-of-pocket expenses. We know that the plans would not be able to provide identical services at the same price, and they would likely go away.

If the administration really believes that the enrollees of private plans are entitled to these extra benefits, then they must believe that those in the more efficient traditional program should be entitled as well. We do still believe that our taxes should be used equitably. Don’t we?

The New York Times
February 14, 2002
By Milt Freudenheim

“Elderly and disabled members of Medicare H.M.O.’s used nearly 50 percent more of their own money on average for medical care in 2001 than they did three years ago, health care researchers said yesterday.”

“Out-of-pocket costs rose 62 percent to $3,578 in 2001 for people in poor health as their share of spending rose for prescription drugs, premiums and other services not fully covered by Medicare.”

Marilyn Moon, a Medicare policy expert at the Urban Institute:

“Many people joined H.M.O.’s to try to reduce out-of-pocket expenses. The bargain was, ‘we will give up some of our control over medical services in order to have some of our costs reduced.'”

John Rother, legislative and policy director of AARP:

“No one is looking at H.M.O.’s any longer as a way of saving money for Medicare. The reality is, fixing these problems is going to cost some money.”

http://www.nytimes.com/2002/02/14/health/14CARE.html

Comment: The Medicare+Choice options were able to offer pharmaceutical coverage and lower out-of-pocket expenses primarily because of their success at enrolling relatively healthy patients. For several reasons, they no longer have the margins that will allow this largess.

The administration and some members of Congress now want to increase funding for these private sector plans which would allow them to continue to offer richer benefit packages. But these plans are not available to everyone, and they vary in their generosity. Why should those that remain in the traditional Medicare program be denied benefits that the private plans provide? They shouldn’t. They should have the same pharmaceutical coverage and reduced out-of-pocket expenses. We know that the plans would not be able to provide identical services at the same price, and they would likely go away.

If the administration really believes that the enrollees of private plans are entitled to these extra benefits, then they must believe that those in the more efficient traditional program should be entitled as well. We do still believe that our taxes should be used equitably. Don’t we?

The Washington Post
February 12, 2002

By Thomas J. Donohue, President and CEO of the U.S. Chamber of Commerce, and John J. Sweeney, President of the AFL-CIO

“When representatives of business and labor meet, it’s usually across the table. Today there is an issue in America that compels us to sit side by side.”

“It is the quiet crisis of the uninsured. For all our miracle cures that are saving lives every day, we have failed to solve our biggest health problem -the fact that so many Americans lack access to even the most basic care because they lack health coverage. It has gotten worse despite good economic conditions, and it certainly won’t improve during a downturn. Today, we are urging our fellow Americans and elected leaders in Washington to join with us and begin the hard work needed to solve this problem.”

“We have different perspectives on the problem, as do our partners in this effort – employers and workers, insurers and consumers, doctors, hospitals and nurses. Though we will undoubtedly disagree on specific solutions, our unified goal is to make the problem of the uninsured our nation’s top health priority and to help America solve it.”

http://www.washingtonpost.com/wp-dyn/articles/A60625-2002Feb11.html

Comment: Another step backwards. “We will undoubtedly disagree on specific solutions,” is a concession that no interested party is willing to abandon its own agenda. And, even though the preliminary findings of the California Health Care Options Project reveal, once again, that single payer models can assure comprehensive health care for everyone while reducing overall health care costs, the parties involved in this latest process have already rejected single payer reform before the discussions begin. They will continue to look at various solutions that the California study indicates will only increase health care costs while perpetuating flawed health policies.

Twelve organizations plus the Robert Wood Johnson Foundation have set up a website for this new effort to publicize the plight of the uninsured and to begin to seek solutions. The website: http://www.coveringtheuninsured.org/

The glossary at this website is revealing in that it includes terms such as medical savings accounts, catastrophic health insurance, purchasing pools, tax credits, refundable tax credits, group insurance, flexible spending accounts, cafeteria plan, FEHBP, HMO, PPO, managed care, and other concepts that the various factions continue to debate. But conspicuously absent from the glossary is which term? Single payer! Not only should it be in the glossary, it should be on the negotiating tables!

http://coveringtheuninsured.org/glossary/

The compromise recommendation that will be reached is quite predictable when considering the organizations that are participating and the positions already taken by each of these entities. The organizations include the U.S. Chamber of Commerce, the AFL-CIO, The Business Roundtable, SEIU, the American Medical Association, the American Nurses Association, the Health Insurance Association of America, Families USA, American Hospital Association, Federation of American Hospitals, Catholic Health Association of the United States, AARP, with the support of The Robert Wood Johnson Foundation. There will be general agreement that public programs should be expanded in order to cover the low-income sector. The affluent will be granted medical savings accounts and other options. And the great compromise will be that tax credits will be accepted as the means of providing access to coverage for the majority. Without elaborating on the serious flaws inherent in this approach, there is no question that the result will be that health care costs will continue to escalate, and greater financial barriers will be erected thereby further impairing access to care.

Representatives of each organization spoke at the press conference announcing this effort. They all agreed that they were committed to compromise with most of them specifying that reform would be “incremental.” Most alarming was U.S. Chamber of Commerce’s Donahue stating:

“The other thing we should know is that there are a lot of private conversations going amongst the people here. I mean, we didn’t just show up here today to, you know, make a statement. We’ve been having a lot of conversation and I’m encouraged by it because it hasn’t got the vitriolic kind of who shot Jack, you know. It’s really-if this is the kind of problem-then how could we fix it and what ways might work.”

“If we move vigorously towards a single payer system which, by the way, doesn’t work anywhere in the world, we’re gonna find a great migration away from the people that are providing the coverage, and we can’t afford that.”

http://www.kaisernetwork.org/health_cast/hcast_index.cfm

The fix is on. They already shot Jack! How could a process that begins with an agreement to keep the strongest advocates of health care justice, the single payer advocates, out of the negotiating rooms ever result in a just health care system? Tragically, special interests already have killed another attempt at rational reform before it even got off the ground.