US backs United Nations measure in favor of universal health coverage

By Elise Viebeck
The Hill, December 12, 2012
The United States has backed a United Nations draft resolution favoring universal healthcare coverage.
The nonbinding measure calls on U.N. member states to ensure citizens’ access to health insurance, and was approved by the U.N. General Assembly on Wednesday.
http://thehill.com/blogs/healthwatch/public-global-health/272625-us-back…
And…

Adopting Consensus Text, General Assembly Encourages Member States to Plan, Pursue Transition of National Health Care Systems Towards Universal Coverage

General Assembly
United Nations, December 12, 2012
Recognizing the intrinsic role of health in achieving international development goals, the General Assembly today – through the unanimous adoption of a resolution on global health and foreign policy – encouraged Governments to plan or pursue the transition towards universal access to affordable and quality health-care services.
By that text, the Assembly, calling for more attention to health as an important cross-cutting policy issue, urged Member States, civil society and international organizations to incorporate universal health coverage in the international development agenda and in the implementation of the internationally agreed development goals, including the Millennium Development Goals.
The Assembly also recognized that improving social protection towards universal coverage “is an investment in people that empowers them to adjust to changes in the economy and the labour market and helps support a transition to a more sustainable, inclusive and equitable economy”.  As such, while planning or pursuing the transition towards universal coverage, Member States were encouraged to continue investing in health-delivery systems to increase and safeguard the range and quality of services and meet the health needs of their populations.
Further, Member States were encouraged to recognize the links between the promotion of universal health coverage and other foreign policy issues, such as the social dimension of globalization, inclusive and equitable growth and sustainable development.
http://www.un.org/News/Press/docs//2012/ga11326.doc.htm
And…

Agenda item 123

United Nations
General Assembly, Sixty-seventh session
Global Health and Foreign Policy
IV. Universal health coverage
56. Universal health coverage captures the aspiration that everyone will be able to obtain the high-quality health services they need without the risk of suffering severe financial hardship when using them. The goal of achieving universal health coverage has two important and interrelated components: coverage for everyone who needs health services (including prevention, promotion, treatment and rehabilitation) and coverage with financial risk protection.
57. Both components are critical to the fulfilment of the highest attainable level of health, a fundamental human right embedded in the WHO constitution of 1948 and in the Universal Declaration of Human Rights. At the same time, people value them for their own sake. They sleep securely at night knowing that the health services they might require are available and of good quality and that they can afford to use them.
http://www.un.org/ga/search/view_doc.asp?symbol=A/67/377
Population figures by country
http://www.nationsonline.org/oneworld/population-by-country.htm

It is terrific that the United States has voted for a United Nations resolution in support of universal health coverage for all Member States. But what about the United States? The Affordable Care Act will leave about 30,000,000 uninsured, more than the entire population of each of 183 countries and territories. Oh, of course… the U.N. resolution is nonbinding.

By Cathy Schoen, Jacob Lippa, Sara Collins, and David Radley
The Commonwealth Fund, December 2012

Across states, the total average premium reached $15,022 per year in 2011 for family coverage, an increase of 62 percent since 2003.

Although premiums are rising more slowly than they were before enactment of the recent reforms, private insurance spending per person is projected to continue to grow more rapidly than incomes over the next decade.

By 2011, there were 35 states in which the annual premium equaled 20 percent or more of income, compared with just one state in 2003. And there are now no states where premiums amount to less than 14 percent of median incomes, compared with 13 such states in 2003.

Although workers are paying more for insurance, their premiums are buying them less financial protection because of the rapid increase in deductibles from 2003 to 2011. The resulting shift of medical care costs onto workers and their families has led to higher out- of-pocket costs for medical bills — on top of higher premium costs. By 2011, 78 percent of workers faced a deductible, compared with about half (52 percent) in 2003.

With the recent recession, millions of workers lost their jobs or were otherwise unable to afford coverage and, as a result, joined the ranks of the uninsured. From 2008 to 2010, the percentage of people with employment-based insurance fell from 58.9 percent to 55.3 percent. An estimated 9 million adults ages 19 to 64 lost a job with health benefits and became uninsured during this period.

Along with rising numbers of uninsured, the nation has seen a rapid increase in the number of underinsured, those at risk of high out-of-pocket costs for medical care although insured all year. As of 2010, estimates indicate 81 million adults under age 65 (44% of all adults) were either uninsured during the year or underinsured, up from 61 million in 2003.

From 2003 to 2010, median family incomes increased by only 10 percent, on average, not enough to keep up with an inflation rate that has increased by 18.5 percent over these seven years.
 
To date, with highly concentrated insurance markets, the path of least resistance for insurers has been to simply pass on the rising costs of medical care and higher prices, while adding insurance administrative costs and profit margins. In fact, the major national private insurance companies have done well throughout the recession years, with strong pretax profit margins and administrative costs that have largely kept pace with increases in medical care costs.
 
The national debate on health care costs often centers on the federal deficit and on Medicare’s future. Less attention is focused on the costs of private insurance spending per person, which have been rising faster than Medicare spending per person and are projected to continue to do so over the next decade. The mounting stresses on businesses and families underscore the need for action on behalf of the private sector as well. Absent a significant change in the way private insurance and health care markets function, cost pressures will continue to push up private insurance costs and out-of-pocket medical expenses, if the past two decades are any guide.
 
The Affordable Care Act’s effectiveness in tackling costs, however, will require collaboration among public and private stakeholders to ensure that markets operate in the broad national interest of better health, more positive health care experiences, and lower future costs.

For full report, click “Issue Brief” at this link:
http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Dec/State-Trends-in-Premiums-and-Deductibles.aspx?omnicid=20

Comment:

By Don McCanne, MD

It just gets worse. Family insurance premiums are now over $15,000 – more than 20 percent of income in a majority of states. Family deductibles now average over $2000. Family incomes have not kept up with inflation, much less with the cost of health care. Yet private insurers are thriving.

Many are hoping that the Affordable Care Act will provide some relief. The PNHP website (www.pnhp.org) has a plethora of reports and studies indicating that there is no hope that that we will have truly substantial reform under this Act – only administratively-complex tweaks.

The authors of this report state that the Affordable Care Act’s effectiveness “will require collaboration among public and private stakeholders.” This is the fundamental reason that there is no hope. Under our current dysfunctional financing system, which was left in place by this legislation, that collaboration must be voluntary – an impossibility since each vested interest is jockeying for the most advantageous position.

Under a properly designed single payer system, the publicly-administered policies are designed to ensure collaboration of all parties. What works in the interests of the patients also works in the interests of the collaborators. Until the nation is ready to demand structural reform that benefits us all, we are going to continue to see the numbers in this report grow even worse.

State Trends in Premiums and Deductibles, 2003–2011: Eroding Protection and Rising Costs Underscore Need for Action

By Cathy Schoen, Jacob Lippa, Sara Collins, and David Radley
The Commonwealth Fund, December 2012
Across states, the total average premium reached $15,022 per year in 2011 for family coverage, an increase of 62 percent since 2003.
Although premiums are rising more slowly than they were before enactment of the recent reforms, private insurance spending per person is projected to continue to grow more rapidly than incomes over the next decade.
By 2011, there were 35 states in which the annual premium equaled 20 percent or more of income, compared with just one state in 2003. And there are now no states where premiums amount to less than 14 percent of median incomes, compared with 13 such states in 2003.
Although workers are paying more for insurance, their premiums are buying them less financial protection because of the rapid increase in deductibles from 2003 to 2011. The resulting shift of medical care costs onto workers and their families has led to higher out- of-pocket costs for medical bills — on top of higher premium costs. By 2011, 78 percent of workers faced a deductible, compared with about half (52 percent) in 2003.
With the recent recession, millions of workers lost their jobs or were otherwise unable to afford coverage and, as a result, joined the ranks of the uninsured. From 2008 to 2010, the percentage of people with employment-based insurance fell from 58.9 percent to 55.3 percent. An estimated 9 million adults ages 19 to 64 lost a job with health benefits and became uninsured during this period.
Along with rising numbers of uninsured, the nation has seen a rapid increase in the number of underinsured, those at risk of high out-of-pocket costs for medical care although insured all year. As of 2010, estimates indicate 81 million adults under age 65 (44% of all adults) were either uninsured during the year or underinsured, up from 61 million in 2003.
From 2003 to 2010, median family incomes increased by only 10 percent, on average, not enough to keep up with an inflation rate that has increased by 18.5 percent over these seven years.
To date, with highly concentrated insurance markets, the path of least resistance for insurers has been to simply pass on the rising costs of medical care and higher prices, while adding insurance administrative costs and profit margins. In fact, the major national private insurance companies have done well throughout the recession years, with strong pretax profit margins and administrative costs that have largely kept pace with increases in medical care costs.
The national debate on health care costs often centers on the federal deficit and on Medicare’s future. Less attention is focused on the costs of private insurance spending per person, which have been rising faster than Medicare spending per person and are projected to continue to do so over the next decade. The mounting stresses on businesses and families underscore the need for action on behalf of the private sector as well. Absent a significant change in the way private insurance and health care markets function, cost pressures will continue to push up private insurance costs and out-of-pocket medical expenses, if the past two decades are any guide.
The Affordable Care Act’s effectiveness in tackling costs, however, will require collaboration among public and private stakeholders to ensure that markets operate in the broad national interest of better health, more positive health care experiences, and lower future costs.
For full report, click “Issue Brief” at this link:
http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Dec/State…

It just gets worse. Family insurance premiums are now over $15,000 – more than 20 percent of income in a majority of states. Family deductibles now average over $2000. Family incomes have not kept up with inflation, much less with the cost of health care. Yet private insurers are thriving.
Many are hoping that the Affordable Care Act will provide some relief. The PNHP website (www.pnhp.org) has a plethora of reports and studies indicating that there is no hope that that we will have truly substantial reform under this Act – only administratively-complex tweaks.
The authors of this report state that the Affordable Care Act’s effectiveness “will require collaboration among public and private stakeholders.” This is the fundamental reason that there is no hope. Under our current dysfunctional financing system, which was left in place by this legislation, that collaboration must be voluntary – an impossibility since each vested interest is jockeying for the most advantageous position.
Under a properly designed single payer system, the publicly-administered policies are designed to ensure collaboration of all parties. What works in the interests of the patients also works in the interests of the collaborators. Until the nation is ready to demand structural reform that benefits us all, we are going to continue to see the numbers in this report grow even worse.

By Elise Viebeck
The Hill, December 8, 2012

Democrats in Congress are changing their tune on means testing in Medicare, an idea the late Sen. Edward Kennedy (D-Mass.) resisted for decades.

Leading Democratic lawmakers have suggested that raising premiums for wealthy Medicare beneficiaries could be a matter of common ground with Republicans in the ongoing deficit-reduction talks.

“I think that is reasonable and certainly consistent with the Democratic message that those who are better off in our country should be willing to pay a little more,” Senate Majority Whip Dick Durbin (D-Ill.) said Thursday.

The idea of affluence testing is not new — wealthy Medicare recipients already pay higher premiums for doctor visits and prescription drug coverage.

But negotiations to avoid the so-called “fiscal cliff” open the door to new measures that would make Medicare costs more progressive based on income.

Last week, Senate Finance Committee Chairman Max Baucus (D-Mont.) called the idea “somewhat attractive” as a bargaining chip for talks on the so-called fiscal cliff.

Sen. Claire McCaskill (D-Mo.) remarked that “Donald Trump may need medication, but he certainly doesn’t need the government to pay for it.”

And Congressional Black Caucus Chairman Emanuel Cleaver (D-Mo.) called means testing a good way to bolster Medicare’s budget without cutting benefits.

“We already have a substantial amount of means-testing in the Medicare program — most significantly, there is no cap on the income subject to the Medicare tax,” said (Rep. Henry) Waxman in a statement to The Hill.

“That is the right way to ask the better-off to pay more. And in fact, we also have means testing now of the Part B and Part D premiums. It is a mistake to go further.”

http://thehill.com/blogs/healthwatch/medicare/271795-dems-warm-to-medicare-change-that-kennedy-opposed

Comment:

By Don McCanne, MD

Now that health care costs are unbearably high, Medicare must be progressively financed since moderate- and low-income individuals can no longer bear the full costs. A major step forward was the removal of the cap on wages subject to Medicare taxes, so higher income individuals pay more. The Affordable Care Act also added a new 0.9% Medicare tax for incomes over $200,000/$250,000.

In addition, in order to help cover Medicaid expansion and subsidies for the exchange plans, the Affordable Care Act also added a 3.8% tax on investment income, again for those with incomes over $200,000/$250,000. So we have already embarked on policies that make health care financing progressive, though we need to do more, but only on the financing end.

Medicare benefits should be the same for everyone. We should eliminate premiums and cost sharing, and we should expand benefits so that administratively wasteful Medigap and retiree health benefit programs are no longer necessary. Low income individuals should receive the same standard of care as the wealthy, just as was the intent in enacting the traditional Medicare program.

Introducing means testing, which we have already begun with Part B and Part D premiums, reduces support of wealthier beneficiaries who are annoyed by these additional charges. Once the principle of means testing is established, the budget hawks ratchet it up, driving wealthier individuals to look for private options, currently available as the Medicare Advantage plans. It is only one small additional step to introduce premium support – vouchers – where the wealthy will take their money and run. Once you lose support of wealthier individuals who have a strong political voice, then Medicare will descend down the path toward becoming a welfare program, like Medicaid.

We cannot allow this bipartisan attack on Medicare to proceed. Mobilize the forces!

Democrats warm to Medicare change that late Sen. Edward Kennedy opposed

By Elise Viebeck
The Hill, December 8, 2012
Democrats in Congress are changing their tune on means testing in Medicare, an idea the late Sen. Edward Kennedy (D-Mass.) resisted for decades.
Leading Democratic lawmakers have suggested that raising premiums for wealthy Medicare beneficiaries could be a matter of common ground with Republicans in the ongoing deficit-reduction talks.
“I think that is reasonable and certainly consistent with the Democratic message that those who are better off in our country should be willing to pay a little more,” Senate Majority Whip Dick Durbin (D-Ill.) said Thursday.
The idea of affluence testing is not new — wealthy Medicare recipients already pay higher premiums for doctor visits and prescription drug coverage.
But negotiations to avoid the so-called “fiscal cliff” open the door to new measures that would make Medicare costs more progressive based on income.
Last week, Senate Finance Committee Chairman Max Baucus (D-Mont.) called the idea “somewhat attractive” as a bargaining chip for talks on the so-called fiscal cliff.
Sen. Claire McCaskill (D-Mo.) remarked that “Donald Trump may need medication, but he certainly doesn’t need the government to pay for it.”
And Congressional Black Caucus Chairman Emanuel Cleaver (D-Mo.) called means testing a good way to bolster Medicare’s budget without cutting benefits.
“We already have a substantial amount of means-testing in the Medicare program — most significantly, there is no cap on the income subject to the Medicare tax,” said (Rep. Henry) Waxman in a statement to The Hill.
“That is the right way to ask the better-off to pay more. And in fact, we also have means testing now of the Part B and Part D premiums. It is a mistake to go further.”
http://thehill.com/blogs/healthwatch/medicare/271795-dems-warm-to-medica…

Now that health care costs are unbearably high, Medicare must be progressively financed since moderate- and low-income individuals can no longer bear the full costs. A major step forward was the removal of the cap on wages subject to Medicare taxes, so higher income individuals pay more. The Affordable Care Act also added a new 0.9% Medicare tax for incomes over $200,000/$250,000.
In addition, in order to help cover Medicaid expansion and subsidies for the exchange plans, the Affordable Care Act also added a 3.8% tax on investment income, again for those with incomes over $200,000/$250,000. So we have already embarked on policies that make health care financing progressive, though we need to do more, but only on the financing end.
Medicare benefits should be the same for everyone. We should eliminate premiums and cost sharing, and we should expand benefits so that administratively wasteful Medigap and retiree health benefit programs are no longer necessary. Low income individuals should receive the same standard of care as the wealthy, just as was the intent in enacting the traditional Medicare program.
Introducing means testing, which we have already begun with Part B and Part D premiums, reduces support of wealthier beneficiaries who are annoyed by these additional charges. Once the principle of means testing is established, the budget hawks ratchet it up, driving wealthier individuals to look for private options, currently available as the Medicare Advantage plans. It is only one small additional step to introduce premium support – vouchers – where the wealthy will take their money and run. Once you lose support of wealthier individuals who have a strong political voice, then Medicare will descend down the path toward becoming a welfare program, like Medicaid.
We cannot allow this bipartisan attack on Medicare to proceed. Mobilize the forces!

John Goodman’s Health Policy Blog
By John Goodman
National Center for Policy Analysis, December 10, 2012

(Excerpts)

Have you ever noticed that people who worry about inequality seem to be focused only on certain kinds of inequality? When they obsess about the income and wealth of the top 1%, they seem to be bothered by only some of those at the top, and not others.

For example, have you ever seen Robert Reich or Paul Krugman or any like-minded complainer bemoan the huge salaries of professional athletes?

Even more puzzling, when is the last time you saw any of them assailing worthless heirs?

Something else is odd about the sociology of the anti-inequality crowd. They seem to be unfazed by inequality created by government.

Take the recent Powerball outcome. At $588 million, it was the largest lottery prize in history ― to be shared by two ticketholders.

Then there is the entire structure of elderly entitlements. They mainly take from people who have less and give to people who have more.

Think about that last finding for a moment. Throughout the country, families who are struggling to get by and who cannot afford to buy their own health insurance are paying 15% of their income to fund hip and knee replacements for our true leisure class, so they can get back out on the golf course.

But when Paul Krugman writes about the top 1%, this is not who he has in mind. He is complaining about the incomes of people who run large companies. He wants their tax rate to be 91%!

I think Ayn Rand may have been right. The left is populated by people who are not especially bothered by those who become wealthy by virtue of birth or luck or good fortune. They do not even seem to be bothered by the winner-take-all feature of professional sports that confers millions of dollars on some athletes while those who were almost as good languish in near poverty. No, who they obsess about are the creators, the builders, the entrepreneurs.

They don’t hate the wealthy who don’t deserve their wealth. They hate the wealthy who do deserve it.

(John Goodman understandably wants his comments to be read in full, which you can do at the following link.)

http://healthblog.ncpa.org/the-anti-capitalist-mentality/

Reader Comments:

Don McCanne says:
December 10, 2012 at 12:30 pm

Although everyone already understands this, it is still important to distinguish between equality and equity. Most progressives are not striving for equality of income and wealth, rather the goal is equity – introduce an element of fairness in distribution.

Although sometimes expressed as an anti-corporate bias, the objection is more to policies favoring massive perverse distributions, as from rent seeking for instance. Rent seeking that provides little net benefit to society while the rent seekers scoop up the wealth, to many of us represents an intense sense of unfairness.

The work of Piketty and Saez demonstrates the unfairness that has now become the norm. In the face of a massive transfer to the wealthy, median household incomes are no longer enough to bring average families the American Dream – paying for essential needs while allowing enough for higher education of their children, adequate retirement accounts, medical costs for those with greater needs, and perhaps even a modest improvement in housing and transportation, and even an occasional well-earned vacation. And keep in mind the obvious that half of all households fall below the median.

With equitable public policies in a wealthy nation like the United States, hard working families should be able to realize the American Dream. That’s fair. What isn’t fair is for the rent seekers to establish a plutocracy and use it to break up our unions, clobber our retirement and health programs, ship jobs out of the country, saddle higher education with intolerable debt, all of this and similar abuses on top of filling their coffers with funds they have wrested away from the main source of our productivity – the workers of America.

Inequality will always be with us, but we do need policies that increase fairness by reducing inequity in America.

http://healthblog.ncpa.org/the-anti-capitalist-mentality/comment-page-1/#comment-137825

Comment:

By Don McCanne, MD

This blog on “The Anti-Capitalist Mentality” does pertain to health care reform in that we will never have an equitable health care system for all until we decide that equity – fairness – must be a primary goal of public policy.

The Anti-Capitalist Mentality

John Goodman’s Health Policy Blog
By John Goodman
National Center for Policy Analysis, December 10, 2012
(Excerpts)
Have you ever noticed that people who worry about inequality seem to be focused only on certain kinds of inequality? When they obsess about the income and wealth of the top 1%, they seem to be bothered by only some of those at the top, and not others.
For example, have you ever seen Robert Reich or Paul Krugman or any like-minded complainer bemoan the huge salaries of professional athletes?
Even more puzzling, when is the last time you saw any of them assailing worthless heirs?
Something else is odd about the sociology of the anti-inequality crowd. They seem to be unfazed by inequality created by government.
Take the recent Powerball outcome. At $588 million, it was the largest lottery prize in history ― to be shared by two ticketholders.
Then there is the entire structure of elderly entitlements. They mainly take from people who have less and give to people who have more.
Think about that last finding for a moment. Throughout the country, families who are struggling to get by and who cannot afford to buy their own health insurance are paying 15% of their income to fund hip and knee replacements for our true leisure class, so they can get back out on the golf course.
But when Paul Krugman writes about the top 1%, this is not who he has in mind. He is complaining about the incomes of people who run large companies. He wants their tax rate to be 91%!
I think Ayn Rand may have been right. The left is populated by people who are not especially bothered by those who become wealthy by virtue of birth or luck or good fortune. They do not even seem to be bothered by the winner-take-all feature of professional sports that confers millions of dollars on some athletes while those who were almost as good languish in near poverty. No, who they obsess about are the creators, the builders, the entrepreneurs.
They don’t hate the wealthy who don’t deserve their wealth. They hate the wealthy who do deserve it.
(John Goodman understandably wants his comments to be read in full, which you can do at the following link.)
http://healthblog.ncpa.org/the-anti-capitalist-mentality/
Reader Comments:
Don McCanne says:
December 10, 2012 at 12:30 pm
Although everyone already understands this, it is still important to distinguish between equality and equity. Most progressives are not striving for equality of income and wealth, rather the goal is equity – introduce an element of fairness in distribution.
Although sometimes expressed as an anti-corporate bias, the objection is more to policies favoring massive perverse distributions, as from rent seeking for instance. Rent seeking that provides little net benefit to society while the rent seekers scoop up the wealth, to many of us represents an intense sense of unfairness.
The work of Piketty and Saez demonstrates the unfairness that has now become the norm. In the face of a massive transfer to the wealthy, median household incomes are no longer enough to bring average families the American Dream – paying for essential needs while allowing enough for higher education of their children, adequate retirement accounts, medical costs for those with greater needs, and perhaps even a modest improvement in housing and transportation, and even an occasional well-earned vacation. And keep in mind the obvious that half of all households fall below the median.
With equitable public policies in a wealthy nation like the United States, hard working families should be able to realize the American Dream. That’s fair. What isn’t fair is for the rent seekers to establish a plutocracy and use it to break up our unions, clobber our retirement and health programs, ship jobs out of the country, saddle higher education with intolerable debt, all of this and similar abuses on top of filling their coffers with funds they have wrested away from the main source of our productivity – the workers of America.
Inequality will always be with us, but we do need policies that increase fairness by reducing inequity in America.
http://healthblog.ncpa.org/the-anti-capitalist-mentality/comment-page-1/…

This blog on “The Anti-Capitalist Mentality” does pertain to health care reform in that we will never have an equitable health care system for all until we decide that equity – fairness – must be a primary goal of public policy.

By Colin P. West, MD, PhD and Denise M. Dupras, MD, PhD
JAMA, December 5, 2012

This study of a large national sample of internal medicine residents confirms that general medicine remains a less common career plan overall than subspecialty medicine. Combined with the fact that only a small minority of medical students express interest in general medicine and primary care careers, the small number of internal medicine residents reporting plans for generalist careers means a very limited number of generalists can be expected to enter practice each year.

http://jama.jamanetwork.com/article.aspx?articleid=1475191#RESULTS

Comment:

By Don McCanne, MD

This update confirms that internal medicine residents are selecting the subspecialties in preference to general medicine and primary care. In light of the pressing need for improving our primary care infrastructure, what policies should we support?

Since family medicine residents almost always eventually enter primary care, should training programs de-emphasize general internal medicine and place more emphasis on family medicine, while relegating internal medicine to the subspecialties? That would improve the allocation of residency slots since you would not be losing general medicine residents to the subspecialties after their residencies began. This is not to suggest that subspecialists should skip all training in general medicine. The purpose would be to stem the loss of generalists from the training programs.

Also many agree that the role of nurse practitioners in primary care should be expanded. This would be especially valuable in integrated health systems and medical homes. If so, the expansion should be coordinated with the family medicine programs to achieve an optimal balance of primary care professionals.

Since we aren’t getting the numbers right, shouldn’t we consider an alternative approach? If we had a federally funded national health program, wouldn’t we be striving to improve the use of our resources to be sure that our health care infrastructure is better balanced? Our current dysfunctional, fragmented method of financing our health care system doesn’t seem to be doing the job very well.