PNHP

Health Care Access for Uninsured Adults: A Strong Safety Net Is Not the Same as Insurance

Health Care Access for Uninsured Adults: A Strong Safety Net Is Not the Same as Insurance

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!

Geography And The Debate Over Medicare Reform

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.

John Q

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.

Personal Costs for Medicare H.M.O.'s Rise

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?

Personal Costs for Medicare H.M.O.’s Rise

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?

Let's Insure America

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.

Let’s Insure America

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.

California HealthCare Foundation Trends and Analysis of Medicare

February 2002
Managed Care Plan Out-of-Pocket Expenses in 2002

In summary, review of the out-of-pocket costs for California consumers enrolled in Medicare+Choice plans for 2002 shows that:

* Premiums are not necessarily an indicator of total out-of-pocket expenses.

* Expenditures are difficult to project at the time of plan selection due to the detail and plan complexity of the terms related to co-payments, deductibles, and coverage limits.

* Total out-of-pocket costs may exceed thousand of dollars over the course of the year.

http://admin.chcf.org/documents/medicare/MedicareTrends2.pdf

Comment: California, the great testing-ground for innovative insurance products, has had more than ample experience with the Medicare+Choice options. The initial perception that these options were successful business models was due to the fact that initial enrollees were a healthy subset of the Medicare population. That subset is now older, less healthy, and more expensive. The magic trick proved to be another illusion. The reality is that these plans cannot provide more services, at a lower cost, while supporting expensive private bureaucracies.

To no one’s surprise, the plans are now in Washington, with hat in hand, pleading for more funds in the face of a Spartan budget. And Tom Scully, Bill Thomas and Nancy Johnson are attempting to change the rules to allow diversion of more funds to this industry, while penuriously posturing by failing to correct the slash in rates that will inflict serious damage to the traditional Medicare program.. They have it wrong. It is not the industry that needs support, but rather the patients. Most urgent is the need for bona fide prescription coverage. Let’s use our Medicare tax dollars for Medicare patients, not egregiously wasteful private bureaucrats.

Emanuel Gale, Emeritus Professor of Social Work and Gerontology, California State University, Sacramento, responds to the California Health Care Options Project:

The HCOP has been an interesting social policy exercise, in moving towards universal coverage.

My personal recommendations for HCOP are that:

1. In the current political climate, a national approach to universal coverage is unrealistic. States must therefore assume a leadership role.

2. The State of California should adopt a Constitutional Amendment that, “Health Care is a fundamental human right for all residents.”

3. There needs to be a priority for developing a “wellness” vs. the current “sickness” model.

4. The authors of the Incremental Reforms collaborate on a single proposal, to maximize the number of uninsured persons to be covered, within a three year time frame. This would be viewed as an interim first step, leading towards a single payer proposal.

5. The authors of the Single Payer proposals and the Employer Contribution proposals, collaborate on a single payer proposal to assure universal coverage, beginning at the end of the three year incremental period, and transitioning over the next five year period.

Without campaign finance reform, there has to be a prohibition of campaign contributions to an elected Health Commissioner, by the vested interests in health care. (e.g. Chuck Quackenbush, former Insurance Commissioner)

Achieving these objectives requires major investments in political and community organizing at the grass roots level, and the political will to foster radical changes in the current “sick” health care system.

California Health Care Options Project

http://www.healthcareoptions.ca.gov/

“An estimated 22 percent of Californians do not have health care coverage. The Health Care Options Project (HCOP), led by the California Health and Human Services Agency (CHHS), is designed to examine various reform options for extending health care coverage in California. The project is consistent with the objectives of Senate Bill 480 signed by the Governor in 1999.

“Nine reform option papers have been developed for HCOP. They include public program expansions, individual and employer tax credits, employer and individual mandates, single payer models, and combination approaches. Two-page summaries and drafts of these proposals are available in the document library of this website. The reform options will be analyzed and compared using a micro-simulation model developed by The Lewin Group under a contract with HCOP. This model is also available in the document library for your review and comment.

“We encourage readers to review these materials and send comments to HCOP at SB480@library.ca.gov. For your convenience, we have added a one-page comment sheet to the document library that you can use to provide feedback on the paper(s) of your choice. These sheets can be returned by e-mail or mailed to Peg Gerould, California Research Bureau, 900 N Street, Suite 300, P.O. Box 942837, Sacramento, CA 94237-0001. Comments will be forwarded to the appropriate authors for their consideration as they continue to develop their reform options.”

The link for the HCOP website: http://www.healthcareoptions.ca.gov/

The brief summaries of each proposal: http://www.healthcareoptions.ca.gov/Summaries_112601.pdf

The comment sheet for providing feedback: http://www.healthcareoptions.ca.gov/webcomments.pdf

The index to the entire HCOP document library, including preliminary full drafts of each proposal: http://www.healthcareoptions.ca.gov/doclib.asp

Comment: You can be a part of this landmark study designed to examine various reform options for extending health care coverage for California, and for the entire nation, since the results of this study will establish a rational basis for reform in all states.

If you are pleased with the status of health care in this nation, then ignore this message and go watch “John Q.” If you believe that efforts must be made to improve our system, then you should participate in this process. It will require some work on your part. But this is finally an answer to the question heard at all health care reform meetings, “What can we do?” What we can do is make this effort to understand various alternatives for reform and then provide an informed input to the process. The various proposals are still being refined. The authors will consider all input during this process.

The remaining comments in this message may reflect my personal bias as a contributor to one of the options, the single payer proposal of James G. Kahn, et al, of the University of California at San Francisco (Kahn, Bodenheimer, Grumbach, Lingappa, Farey and McCanne).

Two single payer proposals (James Kahn, et al, and Judy Spelman) and a health service proposal (Ellen Shaffer) are unique in that they would provide comprehensive health services for everyone. The remaining proposals are best labeled “other proposals,” although some might wish to call them “incremental.” They are a mix of current concepts for expanding coverage, using a variety of mechanisms, resulting in significant differences in the degree to which they accomplish expanded coverage.

Of the “other” proposals, one that I would single out is the proposal of E. Richard Brown and Richard Kronick. Of the proposals that build on our current system, theirs is the most effective and most comprehensive of the choices. It introduces policies that would provide significant improvements in our dysfunctional system. It should appeal to many of those who insist that reform must be incremental, even though some might classify this as more than simply incremental.

But look at some of the reasons that the single payer and health service options should receive very serious consideration:

** They cover everyone.

** They include virtually all beneficial health care services.

** They effectively remove financial barriers to care, an increasing threat to access today.

** They establish equity in health care: equity in funding, equity in access, and equity in allocation of our health care resources.

** And for those that always want to know what the bottom line is in costs, the tentative analysis by John Sheils of The Lewin Group, presented at the symposium in Manhattan Beach on February 8, has demonstrated that all of the “other proposals” will increase health care costs, whereas the three universal proposals will decrease health care costs for California, by billions of dollars.

Although the project is not completed, one conclusion is already clearly evident. These proposals that reduce health care costs attain virtually all of the goals of an ethically-based health care system, whereas all of the proposals that fall short of these goals will increase health care costs.

The proponents of universal coverage should no longer tolerate being left out of the symposia, forums, press conferences, negotiating processes, foundation health care reform projects, or any other arena in which the future of our health care system is being debated. We should let the exclusive club of incrementalists know that we will accept invitations to join in on the process. But, in the absence of such civility, we should considering breaking down their doors. On behalf of all patients, present and future, our voice must be heard.

Don McCanne, M.D. President, Physicians for a National Health Program www.pnhp.org
don@mccanne.org

Robert Isman, DDS, MPH, responds to the California HCOP proposals:

One of the shortcomings of both your proposal and the one from Rick Brown and colleagues is that they both claim to be “comprehensive” in scope, yet neither deals comprehensively with dental services. In your proposal, at least according to the summary that was distributed at the public hearing held in Sacramento a couple of weeks ago, and not answered in direct questioning of Jim Kahn, dental and vision services appear to be almost an afterthought, and will be covered “as the budget allows.” In the Brown et al. proposal, all health care coverage is said to be included for those who do not have current health coverage. The problem with that is that 1) children who would otherwise (i.e., by virtue of family income) be eligible for Healthy Families (California’s SCHIP program), but who have medical insurance but not dental insurance are not eligible for Healthy Families, and presumably would also not be eligible for coverage under this plan; and 2) people covered by Medicare would not be covered by the Brown et al. proposal because they already have coverage, but Medicare does not include dental coverage.

Lack of dental coverage is the most pressing access problem in the US. For every child uninsured for medical care, there are 2.6 uninsured for dental care. About 30% of children who have medical coverage have no dental coverage. As most insurance is employment-based, when people retire, most are covered by Medicare, but as noted above, Medicare doesn’t cover dental care. For every age group, access to needed dental care is cited as a reason for unmet health care needs several times more frequently than access to needed medical care, prescriptions, glasses, or mental health care.

We need to stop looking at insuring different parts of the body with different types of coverage. This situation is perhaps best captured in a statement made by the Coalition for Oral Health during hearings on the ill-fated Clinton health plan:

“Imagine waking up one morning with an excruciating pain in your hand, going to your physician, and having her tell you that you have an abscess on one of your fingers. ‘I can treat it,’ she says, ‘but I’m afraid your health insurance won’t cover it. They don’t cover finger problems.’ Most of us would think this was a pretty strange form of health insurance. If, as most of us now believe, exclusions based on pre-existing conditions, age, and occupational category are wrong, why should we accept exclusions based on parts of the body?

“That is exactly the situation that exists today with respect to oral health care. The mouth is not considered part of the body. While we would be appalled at excluding limbs and organs from coverage, we seem to accept most casually the exclusion of the entire human mouth. If you have an abscess on your leg, your arm–even your face–no problem, you’re covered. If that abscess happens to be in your mouth, inches from your brain, you’re out of luck. This is not rational.”

Comment: Jim Kahn’s silence in response to the question about dental coverage is similar to the long period of silence by Jack Benny when asked during a holdup, “Your money or your life?”

After being asked a second time, he responded, “I’m thinking, I’m thinking!”

Well, Jim was thinking, and he brought the dental and eye care issues back to his writing team. Dr. Isman’s comments are deeply appreciated. He can be assured that Dr. Kahn’s team is revisiting this extremely important health care issue.

Not only does the California Health Care Options Project provide a spectrum of reform proposals, it also provides mechanisms for public input, both through the symposia such as the one in Sacramento mentioned by Dr. Isman, and through the process for public comment mentioned in the earlier message. This time, the public really does have input into the process. Do not miss this opportunity to be a part of the process.

http://www.healthcareoptions.ca.gov/

Editorial: Cuts hurt real people

Gloucester Daily Times
February 6, 2002

“Any politician who supports a tax cut should be arrested, convicted and sentenced to a minimum wage job, ideally a job that has no health insurance. If the politician has a spouse and children, they will probably find themselves eating a meal or two at a soup kitchen and applying for food stamps. They will probably have to visit the local emergency room for routine health care. They will end up praying that their car doesn’t break down, if they can even afford to keep a car on the road. They will suffer indignity, anxiety and hopelessness.

“Voters who support tax cuts and then complain about lousy roads, high housing prices, poor service in deregulated industries such as airlines and cable television, high health care costs and skyrocketing college tuition payments should be arrested, convicted and sentenced to working at a drug clinic. There, they will see real people fighting for their lives to overcome bad choices, mental illness and lack of opportunity. They will realize, it is hoped, that there is not much that separates the haves from the have nots in today’s America.”

“When did America become so cruel? How did our spiritual health become so detached from our material wealth? Is this really the America that Americans want?”

http://www.gloucestertimes.com/

Comment: For those who believe that this must be a emotional expression of the views of an ultraliberal publisher, you should be aware that the Gloucester Daily Times is owned by Dow Jones & Co., Inc.

Medical professionalism in the new millennium: a physicians' charter

The Lancet 2002; 359: 520-22 February 9, 2002

CHARTER ON MEDICAL PROFESSIONALISM

Excerpt:

“Commitment to improving access to care”

“Medical professionalism demands that the objective of all health-care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.”

http://image.thelancet.com/extras/10522web.pdf

Comment: This Charter, which has been labeled “the modern update of the Hippocratic Oath,” was prepared by representatives of the European Federation of Internal Medicine, the American College of Physicians -American Society of Internal Medicine Foundation, and the American Board of Internal Medicine Foundation. It is a call to physicians to reaffirm their active dedication to principles of professionalism.

Professionalism dictates that physicians must strive to eliminate barriers to equitable health care. In the United States, our flawed health care financing creates the greatest barrier to care. It is imperative that we enact reform that eliminates financial barriers thereby providing a system in which other inequities can be more readily addressed. It is not a choice between supporting the self-interests of the business of medicine and the professionalism implicit in supporting health care equity, but rather it is placing professionalism first and then tailoring the business of medicine to fulfill the ideals of the profession.

Medical professionalism in the new millennium: a physicians’ charter

The Lancet 2002; 359: 520-22 February 9, 2002

CHARTER ON MEDICAL PROFESSIONALISM

Excerpt:

“Commitment to improving access to care”

“Medical professionalism demands that the objective of all health-care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.”

http://image.thelancet.com/extras/10522web.pdf

Comment: This Charter, which has been labeled “the modern update of the Hippocratic Oath,” was prepared by representatives of the European Federation of Internal Medicine, the American College of Physicians -American Society of Internal Medicine Foundation, and the American Board of Internal Medicine Foundation. It is a call to physicians to reaffirm their active dedication to principles of professionalism.

Professionalism dictates that physicians must strive to eliminate barriers to equitable health care. In the United States, our flawed health care financing creates the greatest barrier to care. It is imperative that we enact reform that eliminates financial barriers thereby providing a system in which other inequities can be more readily addressed. It is not a choice between supporting the self-interests of the business of medicine and the professionalism implicit in supporting health care equity, but rather it is placing professionalism first and then tailoring the business of medicine to fulfill the ideals of the profession.