(http://www.kaisernetwork.org/health_cast/uploaded_files/BushAdmn.pdf)

“Mr. Scully is the Administrator of the Centers for Medicare and Medicaid Services. And when one reads his remarks on the above cited website, he sounds like a caring and concerned man who truly wants to see the various problems plaguing U.S health care addressed properly.

“BUT, I wonder if Mr. Scully would be so glib about the length of time it may take to ‘fix’ the problems of the elderly, the poor, and the uninsured if he were one of them. With all due respect and honor and sensitivity to the tragic events of September 11th and the aftermath, it did not take us 10 years, or 25 years to get around to responding to the threat and the attack upon our soil and our citizens and residents. The will was there. Miraculously, so was the money.

“What Mr. Scully, and others in this Administration need to do is to simply be honest with the American public. Just admit that the people who have to suffer the consequences of no insurance, no access to care, or have to go without needed drugs because of lack of money to pay for them, these are people who are easily erased from our national consciousness. The above-cited remarks loudly imply that one can ignore these people, MANY OF THEM CHILDREN, with impunity; one can ignore them with little political consequence…after all, they don’t donate thousands of dollars to campaign coffers, they don’t have lobbyists fighting for their cause with money, favors, and patronization.

“But in actuality, we ignore them at great peril to our country and its future. In the process of dismissing the plight of 42 million uninsured, of stating that maybe we can try ‘knocking that down in 10 years’ – down to what, one may ask? – we are institutionalizing a morally outrageous type of dehumanization. Social and economic rights….the right to decent housing, to a basic education, the right to NOT be hungry, and yes, the right to basic health care…are not options … these are necessities for survival. The right to survival is the most basic right of every human being born on this earth. And in the wealthiest country in the world, with the most sophisticated medical technology, and the highest expenditures on health and medical care…this should not even be an issue, it should be a given.

“The number, 40-some million uninsured, is the one that has been getting the most attention recently … as well it should. But that is only part of the U.S. health care system-story. The number is even larger, as many as 55 million, when one counts those who lack health insurance for some part of the year. Another 50 million or so are said to be underinsured, many of them elderly people for whom Medicare only pays about half of medical expenses. All total, somewhere between 35% and 40% of the U.S. population has woefully inadequate or nonexistent financial access to health care. This constitutes a moral, ethical, political, economic, and social crisis for the country as a whole; and if it were ‘fixed overnight,’ that would not be soon enough!”

Barbara Rylko-Bauer, PhD basiarylko@juno.com

New e-mail address for Don McCanne:

don@mccanne.org

Use this address to be added to or removed from the “Quote of the Day” list, as well as for personal communications. Replying directly to a “Quote of the Day” message also will access this address.

Washington, DC
January 16, 2002

Thomas Scully, Administrator of the Centers for Medicare and Medicaid Services:

“… with all the best intentions, we all want to do overnight fixes and fix everything tomorrow. And the system’s too big and the finances are too big, and it just can’t happen.

“So, to some degree, we gotta figure out-we got 42 million uninsured today. How do we get to knocking that down in 10 years? It’s not gonna happen in one year. We don’t have a Medicare drug benefit today. It’s not gonna happen next year. How do we get one in 8 or 9 years that works, that doesn’t blow up the system?

“Medicaid is a wonderful program, but it’s unbelievably, as many of you know, disproportionate in the way it subsidizes people among the states. It needs to be fixed. That’s a morass that’s gonna take 25 years to fix. But I hope, as healthcare policy people, we can start thinking about longer-term goals, instead of the short-term fixes.”

http://www.kaisernetwork.org/health_cast/uploaded_files/BushAdmn.pdf

Comment: With this kind of dynamic leadership, we should have health care reform within… well… uh… maybe not after all… at least during this administration.

Newsday.com
January 17, 2002
by Marie Cocco

“The choice made in 1994 was to let it be, to reject a national solution and let every American find his own. Each employer and each individual would choose in a marketplace that would somehow bring perfect rationality to a perfectly irrational health-care system.

“For that to be true, you would have to believe that economics, and not emotion, is what drives people when they’re having a baby or some tightness in the chest. You would have to assume that people who lose their jobs, and with it their insurance, have a choice. Or that people who go without insurance because they can’t afford the premiums are making an informed decision, not a desperate one.

“Now we know all the old health-insurance problems, and some new ones, are still problems. The question is who, if anyone, will step forward to suggest a real solution.”

http://www.newsday.com/news/opinion/ny-vpcoc172554436jan17.column

Newsday.com
January 17, 2002
by Marie Cocco

“The choice made in 1994 was to let it be, to reject a national solution and let every American find his own. Each employer and each individual would choose in a marketplace that would somehow bring perfect rationality to a perfectly irrational health-care system.

“For that to be true, you would have to believe that economics, and not emotion, is what drives people when they’re having a baby or some tightness in the chest. You would have to assume that people who lose their jobs, and with it their insurance, have a choice. Or that people who go without insurance because they can’t afford the premiums are making an informed decision, not a desperate one.

“Now we know all the old health-insurance problems, and some new ones, are still problems. The question is who, if anyone, will step forward to suggest a real solution.”

http://www.newsday.com/news/opinion/ny-vpcoc172554436jan17.column

Third Edition, 2002 Lange Medical Books/McGraw-Hill By Thomas S. Bodenheimer, M.D. and Kevin Grumbach, M.D.

“Perhaps no tension within the U.S. health care system is as far from reaching a point of satisfactory equilibrium as the achievement of a basic level of fairness in the distribution of health care services and the burden of paying for those services. Despite two years of intense debate on health care reform following the 1992 presidential election, more people in the country were uninsured in 2000 than in 1994, with prospects dim for attainment of universal coverage in this century. Due to persistent financial barriers, more patients will go without early detection of potentially curable cancers, more patients with chronic diseases will be hospitalized because of lack of timely outpatient care, more hypertensive patients will forego the medications that might avert the occurrence of strokes and kidney failure, and more babies will be born prematurely and spend their first weeks of life in a neonatal intensive care unit. The poor will continue to pay a greater proportion of their income for health care than do more affluent families, and catastrophic health care costs will ravage countless middle class families.

“People providing and receiving care in the United States must work together to achieve a brighter future for the nation’s health care system. Changing the future will require that people look beyond their immediate self-interest to view the common good of a health care system that is accessible, affordable, and of high quality for all. A heightened level of public discourse will be needed, with a populace that is better informed and more actively engaged in shaping the future of their health care system. Abstract concepts in health policy will need to be discussed and debated in a manner that connects with the daily realities experienced by patients and caregivers. The attitudes and actions of physicians and other health professionals will play a major role in determining the future of health care in the United States. With leadership and foresight among the community of health professionals, our nation may yet achieve a system that allows the most honorable features of the healing professions to flourish.”

http://shop.mcgraw-hill.com/cgi-bin/pbg/searchresult.html?q=Understanding+Health+Policy&x=14&y=10

Comment: As we contemplate further deterioration in the most expensive but least efficient health care system in the modern world, there has never been a greater need to more thoroughly understand the fundamentals of health policy. Tom Bodenheimer and Kevin Grumbach, in this updated third edition of their classic text, provide a highly readable explanation of policy issues that must be understood by those who wish to help establish an equitable health care system for all of us. It is a great resource for those just learning about health policy. And for those that have more knowledge in the field, it is great for organizing thoughts and approaches to policy issues. It should be in the library of every health care reform activist.

American Medical News
January 21, 2002
Opinion
“The time is right to fix the problem of the uninsured” by Richard F. Corlin, M.D., President of the American Medical Association

“Let’s quickly summarize our AMA proposal:

“We endorse the concept that employers provide a defined contribution for the purchase of health expense coverage — rather than a defined benefit.

“Our proposal supports a system in which all Americans with health coverage are given tax credits — in amounts inversely correlated with their income — rather than excluding employer-provided health benefits from their taxable income.

“We also support the creation of opportunities for alternative health insurance markets — “voluntary choice cooperatives” — that would offer more choices for individuals than are presently available.

“Universally available medical savings accounts play an important role in this consumer-oriented system.”

“And the AMA plan would also help to develop in each and every individual a consciousness of the real costs involved in their health care choices.”

“Let me know what you think about our plan.” richard_corlin@ama-assn.org

http://www.ama-assn.org/sci-pubs/amnews/amn_02/edca0121.htm

Comment: Briefly, the impact of the AMA proposals:

Defined contribution – Results in under-funding of comprehensive coverage, leaving low-moderate and low income individuals with Spartan benefits and greater out-of-pocket expenses, impairing access to care because of lack of affordability

Tax credits – Result in severe under-funding of comprehensive coverage with the same consequences as defined contributions, and threatens the link of health insurance to employment, increasing the numbers of uninsured

Alternative health insurance markets – Creates multi-tiered health care by creating a marketplace for the Spartan plans that a defined contribution or tax credit could purchase, while opening access to all products for the affluent

Medical Savings Accounts – Removes funds from the risk pools for the sick and poor making the Spartan products even less affordable

The AMA proposal is a disaster for those with modest or low incomes. The proposal shifts too much of the responsibility of paying for care to the individuals who have the greatest medical needs. This defeats the fundamental purpose of health insurance, and that is to pool risk, providing security for everyone by shifting the costs of paying for care from the large numbers of healthy individuals to the smaller numbers of those with greater needs. Under the AMA proposal, the affluent can self-fund the deficits, assuring their own security, but modest income individuals will not be able to bear the burden of the costs of major medical problems.

Why would the AMA support such a cruel proposal? Two considerations come to mind. Physicians wish to escape from the restrictions on fees and services that have been characteristic of the age of managed care. Many physicians believe that the AMA proposals will remove constraints on their fees and services. They are content to care for more affluent patients, whereas those that cannot afford their services can be someone else’s problem. Thus the proposal is very self-serving for physicians. The other reason that we can speculate is that the AMA leadership is saturated with political conservatives that ideologically prefer the wealth-oriented policies of the Heritage Foundation (www.heritage.org) to the patient-oriented policies of Physicians for a National Health Program (www.pnhp.org).

Most physicians really do care about patients. Please honor Dr. Corlin’s request to let him know what you think about the AMA plan. His e-mail address is above.

PNHP’s Comments on the Draft of the American College of Physicians -American Society of Internal Medicine Seven-Year Plan to Provide Affordable Coverage for All Americans

By Quentin Young, Don McCanne and Ida Hellander

Overview and Summary of Problems with Corporate Control of Medicine

Despite good intentions, the ACP-ASIM proposal for providing health care coverage for all cannot possibly meet that goal – and delays real reform by seven painful years in which the number of uninsured is expected to rise by 10 million or more. Further, while acknowledging that other problems with our health care system must be addressed, the ACP-ASIM proposal actually perpetuates these problems by keeping intact a system in which greatly flawed health financing and corporate control over health care is an integral part:

– The dominant impediment to decent health care for all is, and has been for two decades, the rapid domination of all aspects of the health system -hospitals, physicians’ practices, nursing homes, etc. – by profit-oriented venture capital. No reform is possible without the correction of this historic shift. The ACP-ASIM proposal is silent on this issue.

– The costs of a multi-payer, for-profit insurance system are so exorbitant as to preclude decent health access for all, not to mention the increasingly neglected sectors of long-term care, mental health services, and prescription drug coverage

– Crucial ethical issues – patient choice, physician’ autonomy, physicians’ ethical responsibility to care for the sick regardless of race, income, or insurance status, “first do no harm”, etc. – are being seriously degraded by the current system. The ACP-ASIM draft does not address the linkage between the delivery system and the systematic denial of services and degradation of medical ethics.

– The ACP-ASIM proposal fails to reject incremental strategies, precisely at the historical moment when employers are bailing out of their workplace insurance commitments and governments are slashing their medical and other health programs. Clearly, single payer national health insurance emerges not any longer as the best solution, but as the only solution!

– The reality that health care is a public good, not a for-profit, investor-owned commodity, has shaped the health programs of all democratic, advanced industrial nations. The ACP-ASIM draft does not examine the lessons our country can learn from the superior achievements – fiscally and medically – of other countries (Canada, Sweden, Norway, etc.).

The single-payer solution:

Universal coverage will never be achieved until we have one single system with an effective method of budgeting and cost control. And quality in health care will not be achieved until we have universal coverage with an effective method of health planning. These are inseparable, and the attempt to take on expanding coverage without reforming the fundamental structure of the health financing system would be like running our government without the Constitution.

Comment: Our response further describes the deficiencies in the ACP-ASIM proposal. By failing to address important policy issues, the ACP-ASIM proposal can never lead to an equitable, affordable system of health care for everyone. We propose an alternative which will accomplish that goal -the single payer solution.

The entire response is available at: https://pnhp.org/pressreleases.html and click on “PNHP’s Comments on the ACP-ASIM Proposal for Health Reform (MS Word document).”

The ACP-ASIM proposal is available at: http://www.acponline.org/hpp/seq_plan01.htm?hp and click on “draft.”

PNHP’s Comments on the Draft of the American College of Physicians -American Society of Internal Medicine Seven-Year Plan to Provide Affordable Coverage for All Americans

By Quentin Young, Don McCanne and Ida Hellander

Overview and Summary of Problems with Corporate Control of Medicine

Despite good intentions, the ACP-ASIM proposal for providing health care coverage for all cannot possibly meet that goal – and delays real reform by seven painful years in which the number of uninsured is expected to rise by 10 million or more. Further, while acknowledging that other problems with our health care system must be addressed, the ACP-ASIM proposal actually perpetuates these problems by keeping intact a system in which greatly flawed health financing and corporate control over health care is an integral part:

– The dominant impediment to decent health care for all is, and has been for two decades, the rapid domination of all aspects of the health system -hospitals, physicians’ practices, nursing homes, etc. – by profit-oriented venture capital. No reform is possible without the correction of this historic shift. The ACP-ASIM proposal is silent on this issue.

– The costs of a multi-payer, for-profit insurance system are so exorbitant as to preclude decent health access for all, not to mention the increasingly neglected sectors of long-term care, mental health services, and prescription drug coverage

– Crucial ethical issues – patient choice, physician’ autonomy, physicians’ ethical responsibility to care for the sick regardless of race, income, or insurance status, “first do no harm”, etc. – are being seriously degraded by the current system. The ACP-ASIM draft does not address the linkage between the delivery system and the systematic denial of services and degradation of medical ethics.

– The ACP-ASIM proposal fails to reject incremental strategies, precisely at the historical moment when employers are bailing out of their workplace insurance commitments and governments are slashing their medical and other health programs. Clearly, single payer national health insurance emerges not any longer as the best solution, but as the only solution!

– The reality that health care is a public good, not a for-profit, investor-owned commodity, has shaped the health programs of all democratic, advanced industrial nations. The ACP-ASIM draft does not examine the lessons our country can learn from the superior achievements – fiscally and medically – of other countries (Canada, Sweden, Norway, etc.).

The single-payer solution:

Universal coverage will never be achieved until we have one single system with an effective method of budgeting and cost control. And quality in health care will not be achieved until we have universal coverage with an effective method of health planning. These are inseparable, and the attempt to take on expanding coverage without reforming the fundamental structure of the health financing system would be like running our government without the Constitution.

Comment: Our response further describes the deficiencies in the ACP-ASIM proposal. By failing to address important policy issues, the ACP-ASIM proposal can never lead to an equitable, affordable system of health care for everyone. We propose an alternative which will accomplish that goal -the single payer solution.

The entire response is available at: https://www.pnhp.org/pressreleases.html and click on “PNHP’s Comments on the ACP-ASIM Proposal for Health Reform (MS Word document).”

The ACP-ASIM proposal is available at: http://www.acponline.org/hpp/seq_plan01.htm?hp and click on “draft.”

The New York Times
January 12, 2002
Letters

To the Editor:

Re “On an Icy Night, Little Room at the Shelter” (Jan. 5):

Very simply stated, in the year 2002 here in the United States, everyone should have a warm and safe place to sleep. There is no excuse for its being any other way.

HAROLD LANGUS Poughkeepsie, N.Y.

http://www.nytimes.com/2002/01/12/opinion/L12HOME.html

Comment: Very simply stated, in the year 2002 here in the United States, everyone also should have health care. There is no excuse for its being any other way.

The New York Times
January 11, 2002
by Robin Toner

“Federal officials confirmed this week that health care costs are climbing faster than they have in years, creating new strains on employers, individuals and government programs that cover the elderly and the poor.”

“… the proportion of people who believe that ‘radical change’ is needed in the health care system has risen, said the Republican pollster Bill McInturff.”

“Not surprisingly, administration officials insist that Mr. Bush will embrace, in his budget, a series of credible health care proposals not unlike what he offered last year – tax credits to help the uninsured buy coverage, particularly people recently laid off, and a new prescription drug proposal for the elderly, tied to an overhaul of Medicare.”

Mark McClellan, a senior White House health care adviser and member of the Council of Economic Advisers:

“The president’s definitely been interested in rising costs. His direction to us has been, if anything, to redouble our efforts to find approaches to keeping coverage affordable.”

http://www.nytimes.com/2002/01/11/politics/11HEAL.html

Comment: Affordable for whom? The answer is that the administration wants to make health care affordable for the payers, specifically employers and the government. But their two primary proposals, tax credits and Medicare premium support, shift the costs to the patients, making care unaffordable for low to moderate income individuals. At the same time, these proposals protect the profits of the private health plans, again at the expense of the beneficiaries.

We don’t need “radical change” that shifts costs to those who are in the greatest need of health care services, thereby expanding financial barriers to care. Instead, we need radical change that establishes equity in our health care system and contains costs through mechanisms that improve allocation of our resources. We need a universal program of social insurance which utilizes global budgeting. And we need it now.

Health Affairs
January/February 2002
by Richard Kronick and Todd Gilmer

“Among persons with income between 100 percent and 200 percent of FPL (federal poverty level), public coverage reduced the number of uninsured persons and crowded out some private insurance. The partial successes achieved by these programs should be kept in perspective: Even after program implementation, approximately 30 percent of low-income adults in the four states were uninsured.”

“If expanded programs of subsidized insurance for low income adults are to greatly reduce the numbers of uninsured persons, they must be designed, implemented, financed, and marketed more successfully than were the programs we studied. Such programs have the potential to reduce private coverage, particularly as they are extended to persons with incomes above the federal poverty level. As has been discussed elsewhere, crowding out of private coverage will result in welfare-improving enhancements for low-income persons but does reduce the program’s target efficiency. Given the pressing problems created by the existence of close to forty million uninsured persons, we think that designing programs to maximize participation should be an overriding policy goal. However, in a voluntary market programs that are attractive enough to enroll large numbers of uninsured persons inevitably will be attractive enough to enroll large numbers of persons who would have had private insurance in the program’s absence.”

Comment: This study demonstrated the important principle that programs of public insurance, such as Medicaid and S-CHIP, may “crowd out” private insurance. That is, these publicly funded programs for lower income individuals may displace health insurance coverage that is currently funded privately (albeit with tax advantages). For individuals with private coverage that shift into the public programs, the costs for this coverage is shifted to the taxpayers even though it does not result in a reduction in the rolls of the uninsured.

There is a much more important principle which this study demonstrates. These programs of public insurance, Medicaid and S-CHIP, after fully implemented, still exclude significant numbers of low income individuals. Further, since states must contribute a component to the funding of these programs, during difficult economic times they are subjected to the guillotine of the budget cutters. Since they are chronically under-funded anyway, these program cuts can be disastrous for our health care delivery system.

There are four lessons here:

(1) Public insurance programs for low income individuals partially miss the target population, insuring the already insured, at the expense of taxpayers.

(2) A program of social insurance should have separate sources of funding that are not admixed with the general budget that is highly subject to political machinations. Although the status of the economy will affect delegated funding for a health care program, problems with funding should not be compounded by injecting the potential for a greater element of political chicanery.

(3) Existing public insurance programs fail to patch many of the holes in the health care safety net, leaving unacceptable voids in health care coverage.

(4) Incremental approaches, most of which include some form of public programs for low income individuals, will never provide the comprehensiveness and equity that is missing from our system. Only fundamental restructuring of health care funding can accomplish that. We desperately need a universal program of social insurance.

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