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

JAMA
May 1, 2002
Book Review by Jerrold P. Schwartz, M.D.

By David Himmelstein and Steffie Woolhandler with Ida Hellander Common Courage Press

“The seven years since the failed attempt of the Clinton administration to enact health care reform have seen the burgeoning of for-profit corporations in all aspects of health care. Giant health insurance and pharmaceutical corporations, for-profit hospital corporations with hundreds of hospitals, hemodialysis and nursing home chains, mental health and home care corporations, and many others less visible, such as quality-of-care and credentialing companies, are now well entrenched in our uniquely American system of health care and are profiting handsomely. But in the free-enterprise free-for-all, how are patients – and doctors – faring? To find out, read this book.”

“Judging by the tone of the book, the authors clearly uphold the US ideals of democracy and egalitarianism.”

“As advocates for our patients and to preserve the ethical underpinnings of our profession, all US physicians should read this compelling argument for medicine as a public service.”

Comment: “Bleeding the Patient” is available from the publisher, Common Courage Press at: http://www.commoncouragepress.com/himmelstein_bleeding.html

An old, dishonorable practice needs to be seen in a new light, namely making people without health insurance pay far more than others for needed health care. This especially affects immigrant groups, and among them, Latinos have the highest rate of uninsurance.

For decades, providers and especially hospitals, have kept raising their charges, far higher than their costs, in order to raise their “profile” for discount payments from government programs and insurers. Each year they raise the charges, and each year the payers respond by lowering the percentage of “charges” they will pay. This game is fine for those in them, and conversations about those not in them usually focus on Sheiks. In a recently conversation, a sub-specialist at a famous hospital was explaining how only millionaires and Sheiks pay full charges – they are so outrageous -and these windfall sums help pay for the uninsured.

But first, the uninsured are billed the “standard charges” (which no insured person pays). Then, when they cannot pay, bill collectors are sent, who attach their credit cards or homes (if they have one), and who threaten to report them to the INS. These charges are typically 3-6 times greater than what is normally collected from HMOs, insurers, and managed care plans. I recently experienced this personally, when a routine blood test was deemed not covered. The lab (a large national company) normally collects $85 for the test from discount contractors, but because they were billing me as an individual, their itemized bill was $401, more than 4 times greater. I got my physician to write a note and the bill was adjusted down to $85. If this had been for a hospitalization, the bill might have been $8500 to a plan or insurer, but $40,100 to an individual.

These practices have been documented by Consejo De Latinos Unidos, and they have a class action suit against Tenet, the huge managed care corporation, for ethnic discrimination. They have even shown in what unsystematic data they have been able to gather, that a hospital recovers more income from uninsured Latinos than from HMOs, i.e., the collection agents get them to pay a third of the bill, or $12,000 before taking them to court and/or getting them deported, when a routine payment would be $8500. Their material include a number of case studies that are an embarrassment to read.

Of course, Tenet replies they are doing what they always do, and that is correct. That’s “how the system works.” The judge on the case happened to speak about it off the record and comments that courts are not set up to change systems. In short, a dishonorable old practice of charge inflation has tragic consequences for the uninsured and especially for immigrants. All discussions about the uninsured, and about individualizing health care by having employees get health insurance for themselves, need to include these issues and practices.

Joanne Landy, Executive Director of the New York Chapter of Physicians for a National Health Program, responds to Rima Cohen on the Health Care Access Resolution – House Concurrent Resolution 99 (HCAR or HCR 99):

I was happy to see on the Q of the D that Rima Cohen, Vice President at the Greater New York Hospital Foundation and Director of the Insurance Options for the Uninsured Project, supports the Health Care Access Resolution – House Concurrent Resolution 99. As a statement committing Congress to enact universal health care by 2004, it is an urgent and necessary resolution.

It’s important to note that HCAR goes beyond calling for universal care; it calls for a guarantee that every person in the United States, regardless of income, age, or employment or health status, has access to decent, humane and affordable care, as detailed in the resolution (see below.)

It is important, however, to urge the public and members of Congress to work simultaneously for a single-payer health care system in the United States that can actually achieve the crucial goals enumerated in HCAR. A single payer system would create a universal risk pool and would finance health care through progressive taxation rather than through an employer-based system that depends on private insurance companies. A single payer system (essentially an improved and expanded Medicare-for-All) would save enormous amounts of precious health care dollars currently spent on marketing, on profits, and on the administrative costs built in to a system that forces providers to comply with hundreds of different insurance plans.

HCAR was introduced by U.S. Representative John Conyers, who is to be congratulated for his vision in doing so. He will shortly be introducing a single-payer health care bill, which will address the question of how to contain health care costs while assuring universal access to quality health care. I hope that Rima Cohen and other supporters of House Concurrent Resolution 99 support the Conyers single-payer bill as well.

HCAR calls for healthcare that: (1) is affordable to individuals and families, businesses and taxpayers and that removes financial barriers to needed care ; (2) is as cost efficient as possible, spending the maximum amount of dollars on direct patient care; (3) provides comprehensive benefits, including benefits for mental health and long term care services; (4) promotes prevention and early intervention; (5) includes parity for mental health and other services; (6) eliminates disparities in access to quality health care; (7) addresses the needs of people with special health care needs and underserved populations in rural and urban areas; (8) promotes quality and better health outcomes; (9) addresses the need to have adequate numbers of qualified health care caregivers, practitioners, and providers to guarantee timely access to quality care; (10) provides adequate and timely payments in order to guarantee access to providers; (11) fosters a strong network of health care facilities, including safety net providers; (12) ensures continuity of coverage and continuity of care; (13) maximizes consumer choice of health care providers and practitioners; and (14) is easy for patients, providers and practitioners to use and reduces paperwork.

Does anyone seriously believe that our private, employer based heath care system can deliver this package? To ask the question is to answer it.

–Joanne Landy Executive Director Physicians for a National Health Program New York Chapter

Comment: It is very easy to ask your member of Congress to support House Concurrent Resolution 99 by sending a message through the following link: http://www.house.gov/writerep/

America’s Health Together (www.healthtogether.org)
April 30, 2002
Washington, DC

Rima Cohen,Vice President at the Greater New York Hospital Foundation and Director of the Insurance Options for the Uninsured Project, whose mission is to devise and implement strategies for expanding health insurance coverage in New York:

… we know for sure that the market has not taken care of the problem. Indeed, about a million people every single year since the census began collecting these statistics, have been added to the ranks of the uninsured. So, that’s a difficult thing for me to grapple with looking back on so many years working on health insurance coverage.

So, I jumped at the chance to move into the state health policy arena, thinking that this is where the action is going to be in the coming years, and to a certain extent, I was right. And I was very fortunate when I moved to New York to be involved with an effort that started off with a coalition of organizations where we developed a health insurance plan that was meant to build on our Child Health Plus Program. It was for parents and childless adults, and within a couple of years of my arrival in New York, that legislation passed into law. And, it was the single biggest expansion in New York’s history since–or I should say, since the creation of Medicare and Medicaid in 1965.

So, having been through that experience, you would think that I might be a big advocate of states as the laboratories of democracy, states experimenting with health insurance coverage initiatives, maximum state flexibility to develop locally tailored solutions to the health insurance crisis, but actually, I came away with exactly the opposite sense.

… health insurance coverage is really something that should not be thrown onto the states. And indeed, New York, with all the fanfare of this huge health insurance expansion, we really have not seen a drop in the uninsured. I think all we’ve done is managed to keep people–more people from losing their coverage.

So, let me just tie this all together with a couple of pearls of wisdom that I think can be used to think about strategies going forward. And the most important one is the one that I call, “Bigger is better when it comes to health insurance coverage.” And what I mean by that is, the lens through which I look at every health reform solution is always, “Does it pool the greatest number of people in the largest pool and the greatest number and the most diverse in terms of their ages and illnesses and so forth?” Because that’s the only way that health insurance works.

Health insurance does not work when people can segment themselves into tiny groups and divide themselves based on their illnesses or even geography or their age. And the system now really divides people, and what we really should be doing is pooling people. That’s the principle of health insurance and that’s why–one of the reasons why I think a resolution like this is so important. It’s saying, “Everybody needs health insurance coverage. Let’s pool the largest number of people together,” and a corollary of that is, “Don’t be fooled by calls for more choice.” I think all Americans want choice of their health care providers. I don’t see individuals clamoring as much for their choice of health plans, their–lots of other kinds of choices that you hear set up. Choices of benefit packages. That only allows people to segment themselves again. We need to be thinking about large solutions, comprehensive solutions. That’s the only way we’re really going to–to see a real program for all Americans.

And that’s why I think a Resolution like this is so important (H Con Res 99). Because it doesn’t say that this is exactly the way the health–the health care solution has to be built, but it says, regardless of the method, it has to be done. And the appropriate place to start is in the U.S. Congress passing this resolution, saying that by a date certain, the feds will come up, hopefully in partnership with the states and with lots of organizations that care about this issue, will come up with a solution but it cannot be done by states alone.

For the transcript: http://www.kaisernetwork.org/health_cast/uploaded_files/Transcript_HealthTogether.pdf (cut and paste to rest of link)

For House Concurrent Resolution 99: http://www.house.gov/conyers/hr99.PDF

The resolution calls for legislation by October 2004 that would guarantee that every person has access to health care that meets fourteen specific criteria that we all support. Read it, and then contact your Congressional representative to enlist his or her endorsement.