BMJ 2001;323:1440-1441
December 22-29, 2001
Editorials

“The newly qualified doctors of Imperial College School of Medicine recently adopted a ceremony in which they declare their commitment to assume the responsibilities and obligations of the medical profession. The decision to create a declaration ceremony was widely supported by the final year students and it reflects a recent resurgence in interest in medical oaths in the United Kingdom.”

“The increasing complexity of healthcare arrangements and interagency collaboration, and the need to look at rationing resources, has forced the medical profession to re-examine its core values. In view of this, and with public confidence in doctors diminishing and morale at an all time low, it is perhaps unsurprising that the concept of an entire year of newly qualified doctors freely declaring their intentions to act ethically and professionally proved popular with both staff and students at Imperial College.”

An excerpt from the “Declaration of a new doctor”:

“I will strive to change laws that are contrary to my profession’s ethics and will work towards a fairer distribution of health resources.”

For the entire declaration: http://bmj.com/cgi/content/full/323/7327/1440?eaf

Comment: With only 6% of their GDP devoted to health care, these young British physicians have a significant challenge in being certain that their resources are distributed fairly. Their efforts need to be directed to increasing the budget for health care.

With access to 14% of our GDP, our young physicians should have relatively negligible challenges in distributing our health care resources fairly, if it weren’t for the intrusive health plans with their fragmented coverage. The real challenge is to change the laws to provide a system of public administration and universal coverage that would enable fair distribution of our abundant resources. Striving for these changes would represent the finest of our Hippocratic traditions.

World Health Organization Press Release
December 20, 2001
Commission on Macroeconomics and Health

“A drastic scaling up of investments in health for the world’s poor will not only save millions of lives but also produce enormous economic gains, say experts in a landmark report presented today to the World Health Organization (WHO).

“A group of leading economists and health experts maintain that, by 2015-2020, increased health investments of $66 billion per year above current spending will generate at least $360 billion annually. About half of this will be as a result of direct economic benefits: the world’s poorest people will live longer, have many more days of good health and, as a result, will be able to earn more. The other half will be as a consequence of the indirect economic benefits from this greater individual productivity. It will mean a total economic gain of at least US $360 billion per year – a six-fold return on the investment.”

http://www3.who.int/whosis/cmh/cmh_press/e/who_hq_20Dec2001.pdf

For the entire report, “Macroeconomics and Health: Investing in Health for Economic Development”: http://www3.who.int/whosis/cmh/cmh_report/e/report.cfm?path=cmh,cmh_report&language=english

Comment: This report demonstrates that it makes economic sense to invest in the health care of the people of poor nations. Although it is disconcerting for health care professionals to see spending on health care reduced to a mere formula for calculating dollar return on investment, there actually is good news here.

Currently, the 60 poorest countries spend $13 per person per year on health care. For comparison, the United States spends $4500 per person per year. The report shows that increasing the level of spending in poor countries to $38 per person would be adequate to fund essential health interventions.

As health care professionals, our first concern is preserving the maximum number of quality years of life possible, referred to by economists as disability-adjusted life years. This modest increase in spending in poor countries would save 330 million years of quality life for the 8 million lives saved each year.

Whether you are an economist looking at the dollar return, or a health care professional looking at the real value in improved health, this is an investment that the world must make.

American Medical News
December 24/31, 2001

Number of applications to medical schools:

1996-1997 school year – 46,968 2001-2002 school year – 34,859

“Experts cite loss of physician autonomy and the high cost of medical education as two reasons for the decline.”

http://www.ama-assn.org/sci-pubs/amnews/pick_01/prca1224.htm

Comment: Opponents to national health insurance frequently claim that adoption of a program of government insurance would result in a decline in the number of qualified applicants for medical school. If the number of qualified applicants is to be used as a parameter of the quality of our system, then it is quite clear that we can no longer accept the status quo.

It probably is true that individuals who place the highest value on the opportunity to maximize income may not be attracted to a system in which compensation is adequate but not excessive. But then our health care system is not well served by those individuals that continually manipulate the system to maximize profit.

We would better be served by individuals that maximize the dignity and value of human life, and who are quite content to practice medicine in an environment in which the medical decisions lie within the physician-patient partnership, while financial decisions are removed from the day-to-day medical considerations.

A publicly administered program of universal health insurance would assure potential physicians of a favorable practice environment and adequate compensation, thereby assuring the rest of us that there will always be a generous pool of qualified medical school applicants.

The Washington Post
December 19, 2001
by Glenn Kessler and Juliet Eilperin

“The stimulus bill has been mired in disputes between Democrats and Republicans over the best mix of tax cuts and spending, but the biggest hurdle in recent days has involved health insurance. The issue has prompted a fierce philosophical debate, with Republicans pushing individual tax credits and Democrats arguing to keep such credits within the employer-based system.”

“House-Senate negotiators had met for barely an hour last night when Rep. Bill Thomas (R-Calif.), chairman of the negotiations, left to go to a vote. Participants said he then phoned the negotiating room and informed the other negotiators he was terminating the meeting and not returning.”

Rep. Bill Thomas:

“There are people who are employed and do not get health insurance. If we get a structure, it ought to be available to them when they are working. Why would it be available to them only when they are not working?”

http://www.washingtonpost.com/wp-dyn/articles/A62608-2001Dec18.html

Comment: Whether the tax benefit of purchasing insurance coverage accrues to the employer or to the employee seems like a minor issue, especially when considering that most economists consider health coverage to be part of the employee’s compensation package anyway. Besides, as Rep. Thomas points out, tax credits could also assist employed but uninsured individuals to purchase health care coverage. What could be wrong with this? Well, plenty.

Employers are looking for ways to escape the burden of escalating costs of their health benefit programs. Many are switching to partial payment through defined contribution approaches to coverage, if not outright terminating employee coverage. Granting tax credits to employees will encourage employers to shift the responsibility of purchasing health care coverage to the employee in order to take advantage of the tax benefit. Since tax policy carries the endorsement of our government, employers would be relieved of much of the guilt they might have by making this change.

By converting to the equivalent of vouchers or cash, employers will have fulfilled their responsibility, and employees are left to fend for themselves in the health care marketplace. The defined contribution received by the employee would be inadequate to purchase comprehensive coverage, and so the employee is left with either an inadequate plan, or very likely, pocketing the allowance and taking a chance on not having catastrophic health care losses. Thus tax credits for individuals will severely damage or destroy the link between health care coverage and employment, resulting in dramatic increases in the numbers of uninsured and under-insured.

There are other issues. Individuals in the health insurance market are vulnerable, having to pay higher premiums than with group coverage, and not being able to obtain affordable coverage if they have pre-existing disorders. This is great for insurance industry profits, but terrible for beneficiary-patients.

By making the patient the decision maker in health care purchasing, tax credits support the consumerism movement in health care. As we have seen previously, consumerism shifts costs to those that need care, threatening affordability and access for those with major acute and chronic disorders.

Individual tax credits are being supported by conservatives as the answer to the covering the uninsured. But it is very clear that the credits will never, never be large enough to assure affordability of health care coverage. Credits will be used primarily by those who now receive coverage through their employment or by those who can afford to purchase coverage on their own. As targeted tax policy, it entirely misses the target.

In the future, the linkage between health care coverage and employment should be terminated as we place everyone into a universal program of health insurance. But until then, it is absolutely essential that we continue with policies that encourage maximum employer participation in the health benefit programs for the employees. Failing to do so will only increase the numbers of the uninsured and under-insured.

The Washington Times December 18, 2001 by Guy Taylor “Sparks flew yesterday at the D.C. Council’s public oversight hearing on the D.C. Health Care Alliance, a group of private health care contractors hired by the city last may to replace D.C. General Hospital as the District’s main provider of public health services.” Washington, D.C. council member David A. Catania, at-large Republican: When D.C. General closed, the residents of the District “were promised 34 percent more care at 25 percent less cost – what we’re getting instead is 18 percent less care than we were getting last year at no cost reduction.” http://www.washtimes.com/metro/20011218-27752680.htm Comment: When the conservative Washington Times quotes a Republican council member complaining about a system of privatized health care, we know that history has been made. Now that we agree that the government can increase the efficiency of our health care system, let’s get on with defining the precise role that it should play. (Hint: a publicly administered program of universal health insurance.) This message from Dr. Quentin Young to PNHP members and friends is being forwarded to the members of the “Quote of the Day” list. For many of you, this is a duplicate message, and please accept our apologies for that. Surveys suggest that there is strong support amongst physicians for replacing our defective, inefficient, inequitable, wasteful, fragmented system of health plans with a national health insurance program. The prevailing rhetoric suggests that physicians remain uncomfortable with this approach. There is a pressing need to change the rhetoric to reflect the true level of physician support for reform. This is the purpose of this campaign. For health care justice for all, Don McCanne, M.D. President-Elect, Physicians for a National Health Program ***************************************************** December 18, 2001 Dear PNHP Members and Friends, We need your help. The next issue of the PNHP newsletter (52 pages of articles, updates, and analyses of current health policy and politics) is finally put to bed and at the printer. We hope that you’ll find it as valuable as past issues. While we plan to continue our impressive coast-to-coast educational program, we believe the devastation inflicted by for-profit corporate ascendancy over the health care system has moved a critical mass of our profession into readiness to support single-payer national health insurance. The time is at hand for a major expression from America’s doctors. In 2002, PNHP intends to launch an ambitious new campaign to reach America’s 700,000 physicians with our updated proposal for national health insurance. Obviously this is a great undertaking which will require major resources. Our present funds will allow us to reach only one out of seven doctors. Our goal is to reach every physician.Your tax-deductible gift will allow us to reach more physicians. Please consider donating on-line at www.pnhp.org or through the mail to PNHP, 29 East Madison, Suite 1412, Chicago, IL 60602. Your newsletter packet will also include a card and return envelope, but with the holiday mail rush, we wanted to make sure you could donate before the end of the tax-year if you wish. Thank you in advance for your generous support. Quentin Young, MD PNHP National Coordinator pnhp@aol.com (312) 782-6006 P.S. For every $100 donated, we can reach 250 more physicians. Please help us reach out and give voice to our profession! ******************************************************* PNHP National Physician Outreach Project, 2002 – Gift Card 29 East Madison, Suite 1412, Chicago, IL 60602 Enclosed is my contribution of: _____ $1000 _____$500 ______$250 _____$100 $_______ Other Form of payment: _____ Mastercard ______ Visa ______ Check (make payable to PNHP) Card # _________________________________________ Exp._______________ Name________________________________________ (e-mail or phone)__________________________ Address ____________________________________ __________________________________________________________________ (If you wish to be removed from the “Quote of the Day” list, please return this message with the word “Unsubscribe” in the subject line.)

The New York Times
December 17, 2001

Excerpt from the letter of David Jones, President, Community Service Society of New York:

“In New York, there have been more than 100,000 new Medicaid applicants since the state began its disaster-relief Medicaid program after the events of Sept. 11. This dramatic response brings to the fore a significant problem: the many people in need of health coverage but not enrolled in programs.”

http://www.nytimes.com/2001/12/17/opinion/L17MEDI.html

Comment: Current political approaches to the problem of the uninsured are limited to the concerns of those individuals losing coverage because the September 11 disaster and because of the recession. Attempts to expand public programs for the chronically uninsured, especially Medicaid and S-CHIP, are failing because of balanced-budget mandates at the state level.

If a publicly administered program of universal health insurance had been in place, we would not be concerned about these issues since everyone would already have coverage. Instead, the political debate would be over debt management and taxation, a debate that we already have and always will have. Wouldn’t it be better to assure health care coverage for everyone and then go back to the tables and limit our debate to tax policy?

Alliance for Health Reform

December 12, 2001
Washington, DC

During Q & A:

Edward Howard, Executive Vice President, Alliance for Health Reform:

“I do have a couple of questions that have been submitted in advance, and let me try one of those, if I can. The questioner starts by noting the inability of employers to protect themselves from rising health insurance premiums compared to, for example, their domestic competitors who provide nothing, their global competitors who have access to a universal system. Also the lack of effective cost containment in a highly fragmented system. Given that, whatever merit employer-sponsored health insurance offered to spread risk equitably through the population, isn’t this a good time to create more equitable risk pools at the state or community level? Lynn, you sort of had some notions along that line.”

Lynn Etheredge, an independent health policy consultant:

“Thanks, Ed. All I can say is that, what we’ve discovered in health insurance debates is that one person’s-when people start talking about equity, they’re talking about reallocating costs to someone else. And, while it may, for the person who’s suddenly hit with a double digit rate of increase after several years of single digit, the idea that it’s more equitable to shift that cost to someone else, to the person to whom it’s shifted, who’s already also facing a double digit rate of increase, the willingness to think it’s equitable to pay someone else’s bill on top of theirs is somewhat diminished. So I’m not sure that it’s-theoretically, it might be a good time to do it but, in practice, we-it makes it somewhat harder I think.”

And later,

Mr. Howard:

“Stuart, you were talking about a voluntary system, and I wonder if you have any current thoughts about the idea of an individual requirement for insurance purchase, in the way that many states have individual requirements for auto insurance purchased for those who want to have licenses to drive, and whether or not that idea is getting any sort of receptivity from that broad spectrum of folks that you were talking about earlier.”

Stuart Butler, Ph.D., Vice President, Heritage Foundation:

“Well, you know, the wounds I suffered when I last proposed that are only just beginning to heal now! I mean, look, in principle-I’m a conservative. In principle, I have no problem with the idea of saying that the rest of society should be protected against individuals who use our existing laws and good nature to provide them with a service that they’re not prepared to pay for. I think that we should have a requirement for at least that. Whether we should have it beyond that, is much more open to question. But I still think that there are other kinds of soft ways in which one can achieve the same kind of objective. I mean, the various tax proposals that are on the table and other subsidies basically say, unless you get at least a minimum protection, you don’t get any of these. You don’t get any subsidy for your prescriptions, for your-you know, for your visit to the doctor or anything. That’s an inducement.”

“There are proposals from, I think NCPA and others that say, okay, what-let’ s take the people who just, whatever you try to do, still don’t sign up. Well, let’s calculate some of those and give the state the equivalent money and let them deal with those people directly, which at least is better than we have today. So I think there are ways. But I certainly feel that there ought to be a requirement for at least a minimum protection, much like, as you said, third party insurance for automobiles, because I don’t see why I should pay because somebody runs into me. And, you know, those kinds of things I have no problem with.”

http://www.kaisernetwork.org/health_cast/uploaded_files/kff121201a.pdf

Comment: These unprepared responses during the question and answer session demonstrate the difficulty that those who are opposed to a program of universal insurance have with the concept of equity. It seems that achieving equity or fairness should be at the forefront in our efforts to reform health care. A suggestion for the topic of the next forum: “Health Care Equity: How Can We Achieve it?”

Tom Mainor, Pastor of Shady Grove Presbyterian Church in Memphis, responds to Jeff Huebner’s comments on the ACP-ASIM proposal:

These observations are helpful. There really seems never to have been a lucid and rational national discussion, with helpful media coverage, of what we mean by “single payer approach.” They are always side-tracked by the opponents of a universal system, and mis-characterizations by entrenched financial interests who want to get control of community-provided health resources for profit.

The suggestion re/ modeling them after the Canadian provincial system parallels my thinking that regional health systems, globally budgeted, with regional health councils that look at everything from prevention, to trauma, to cure and rehab, nursing home care and good public health structures–such an approach can blunt the objections to universal coverage, and remind us that “government” is “we the people” working together to do what needs to be done for the commonweal. We would not suggest that only those citizens who can afford it have safe drinking water, or fire and police, or Coast Guard or a competent and ready national defense force. Why should health care be left to the vagaries of a market place whose purpose is to create more customers rather than a healthy people?

Tom Mainor

The New York Times
December 12, 2001

To the Editor:

“A New Health Plan May Raise Expenses for Sickest Workers” (front page, Dec. 5) points out the downside of a new approach to corporate expense reduction. The employers’ share of a new health care product would decrease, as would the average premium, but the burden would be shifted to sick people!

This is unwise public policy. When seriously ill, most patients are not working, and their families are burdened by additional expense already. And if the major costs of modern medicine are shifted directly to patients, they are more likely to defer diagnostic procedures and filling prescriptions, and therefore get sicker. Sooner or later, we will all get the bill.

When are we going to realize the humanity, and the wisdom, of community-wide risk pools, which would spread the burden fairly to all? When will we realize the economy and efficiency of a national insurance system?

Steven Wolfson, M.D.

New Haven, CT

http://www.nytimes.com/2001/12/12/opinion/L12HEAL.html

The Times-Standard Eureka, California
December 09, 2001
by Jennifer Morey

“When an insurance company executive has the audacity to admit to a state senator that his company doesn’t offer drug and alcohol treatment coverage because it simply doesn’t want to spend the money, it’s a clear illustration of the severity of the health care crisis. Studies have shown that treatment is cost-effective and saves companies millions of dollars, but that doesn’t matter to this executive.”

California state Sen. Wesley Chesbro, quoting the executive:

“It’s fairly simple. We are an investor-owned company. The decision is based on actuarial data. By the time the catastrophic costs are incurred, the person will no longer be employed.”

http://www.times-standard.com/Stories/0,1002,2896%7E264943,00.html

Comment: Sen. Chesbro’s hearing was held in rural Humboldt County, a region that is partially dependent on the fragile economy of the fishing and lumbering industries. Managed care plans have failed to enable affordable access to care in Humboldt County and in other rural areas of California. Rather than seeking solutions on how to make managed care plans work for rural communities, we should be advocating for equitable distribution of our resources. A publicly administered program of universal health insurance would assure rural communities that adequate health care resources would always be available to them, and to the rest of us as well.