PNHP

'Single payer' still their goal

'Single payer' still their goal

By BENNETT HALL
Corvallis Gazette-Times,  March 12, 2011

Shortly after noon on Friday, state Rep. Michael Dembrow stepped to the microphone and addressed a crowd of about 150 people gathered on the steps of the Oregon Capitol in Salem.

“You look so healthy,” he told his audience. “You must all have good health insurance.”

The line got a big laugh for the Portland Democrat, as he must have known it would. Dembrow is the chief sponsor of House Bill 3510, the Affordable Health Care for All Oregon Act, which would all but eliminate private health insurance in Oregon and replace it with a taxpayer-funded system covering everyone in the state: single-payer health care.

Dembrow’s bill was scheduled for a hearing before the House Health Care Committee on Friday afternoon, and the lunchtime rally on the Capitol steps was a bit of political theater calculated to show support.

Toting signs with slogans such as “Patients Not Profits,” “Single Payer Now!” and “Everybody In, Nobody Out,” the crowd chanted and cheered for more than an hour as speaker after speaker slammed the insurance industry, shared horror stories of Americans bankrupted by medical expenses and called on the legislature to enact Dembrow’s proposal.

The really funny thing was, none of them seemed to think it has a ghost of a chance.

Rep. Jules Bailey, one of the bill’s co-sponsors, exhorted the crowd to settle in for a long fight.

“Don’t stop,” Bailey said. “If we don’t get there right away, we will get there eventually. We will get there.”

As Dembrow himself put it, “It’s not all about the bill. Single payer is a movement.”

‘A long-term effort’

For hardcore health care reformers, single payer is the holy grail, a system that would rein in out-of-control medical costs while extending coverage to everyone. But they face determined and well-financed opposition from insurers, pharmaceutical companies and tea party Republicans, who deride the idea as socialized medicine.

HB 3510 is not the first attempt to create a single-payer health care system in Oregon. That distinction belongs to Senate Bill 1066, which was introduced in 1995 — and promptly faded into obscurity.

The issue was resuscitated in 2002, when Health Care for All-Oregon mounted a statewide signature-gathering campaign that succeeded in placing Measure 23 before the voters — who shot it down by a 700,000-vote margin.

Now it’s back, and while Dembrow has no illusions that his bill will pass, he’s crossing his fingers that it will stay alive long enough to generate some genuine discussion in the legislature. He has two co-sponsors on the Senate side, where he’s hoping the proposal could get additional hearings.

If he can get enough lawmakers interested in the concept, they might be willing to commission an in-depth cost analysis, a step that could build additional support. And even if 3510 dies this session, as expected, he’ll push to send it to Oregon voters again as a referendum, possibly in 2013.

“The likelihood of this bill passing and us having a single-payer system in the next year or two is remote,” Dembrow acknowledged in an interview last week.

“I see the effort for single payer as being a long-term effort,” he added. “There is still a lot of education that has to happen and a lot of organizing that has to happen, and this bill is a vehicle for that.”

Coalition-building

As health care costs continue to rise faster than American incomes, more and more people are flocking to the single-payer banner. In Oregon as in other states, the coalition that has formed around the issue includes labor unions, doctors and nurses, churches and social justice organizations, all of which were well represented at Friday’s rally in Salem.

Peter Shapiro was the master of ceremonies, introducing the speakers and setting the tone for the event with his rabble-rousing commentary.

A retired mailman who now works as an organizer for Portland Jobs With Justice, Shapiro urged the audience to fight back against the attacks on public employee unions around the country.

“I have one of those gold-plated plans,” he told the crowd. “I’m one of those people you’re supposed to hate. And 25 percent of my federal annuity goes to insurance premiums.”

In an interview, Shapiro talked about organized labor’s shift toward single payer after years of fighting to protect hard-won insurance benefits — often achieved at the cost of significant concessions on wages.

“It’s a difficult transition for union members to make. It’s a mark of how badly our health care system has deteriorated,” he said.

“More and more unions are realizing we’re living on borrowed time as far as benefits are concerned, and they’re paying a greater and greater price to keep those benefits at the bargaining table.”

Portland Jobs With Justice has thrown itself into the campaign for single payer, reaching out to other labor organizations to broaden the coalition supporting HB 3510. So far, nine Oregon unions have officially endorsed the measure — including two that represent teachers, often targeted for having Cadillac health benefits.

In January, Shapiro helped organize a highly successful conference on single payer in Portland. More than 400 people turned out for the event, which featured keynoters such as Dr. Margaret Flowers of Physicians for a National Health Program and Michigan Rep. John Conyers, one of the champions of single payer in Congress.

And on Friday, Shapiro brought a dose of fiery union rhetoric to the rally for HB 3510.

“We have the most profit-driven health care system in the world, and you see where that gets us,” he reminded the crowd as the event came to a close.

“The fact of the matter is, health care is not a commodity, it is a human right. And we are not consumers of health care, we are human beings!”

Mad as hell

Radiation oncologist Mike Huntington of Corvallis has devoted himself to health care reform since retiring in 2006. He became convinced of the need for change after seeing too many of his patients delay treatment because they lacked insurance coverage, with disastrous results.

“I saw it happen so often that it made me sick and then sad and then mad,” Huntington said.

In 2009 Huntington and fellow Corvallis physician Paul Hochfeld helped launch the Mad as Hell Doctors, an Oregon offshoot of Physicians for a National Health Program. The group mounted a cross-country tour, holding raucous single-payer rallies in more than two dozen cities en route to a demonstration on the White House lawn in a bid to influence the congressional debate on health care reform.

No trace of single payer made it into the federal health care reform law, which failed to include even the “public option” initially promoted by President Barack Obama.

But the Mad as Hell Doctors are still on the case. Last year they staged a California road trip to promote a single-payer measure in that state, and they’ve been touring Oregon for several weeks in support of the Dembrow bill.

On Friday, a white-coated contingent of Mad Docs was on hand for the Capitol rally, including Huntington.

The way he sees it, the financial logic of single payer is simply inescapable.

“Even health insurance CEOs privately say it. How can health care expenses keep increasing 25 percent a year? Eventually they’ll run out of customers,” Huntington said in an interview before the rally.

“It’s a false reality, and I’m going to stick around until the real reality is too hard to ignore.”

In it for the long haul

Betty Johnson is a battle-scarred veteran of the fight for sin
gle-payer health care in Oregon. She got involved in health care reform in 1991 through her church, and her faith continues to inform her work for the cause.

“It is a moral imperative to ensure that everyone has the health care they need,” she said.

The Corvallis resident, a widely respected leader in the state’s Health Care for All chapter, was a key player in the campaigns for SB 1066 and Measure 23 and now is pushing hard for HB 3510. In fact, she had a hand in writing all three proposals.

Johnson attended the rally, too, but before that she led a small cadre of Corvallis and Albany health care activists through the Capitol corridors on a mission to lobby as many lawmakers as possible to support HB 3510.

The group started on the House side of the building, stopping by the offices of Sara Gelser, Jim Thompson and Andy Olson before crossing over to the Senate wing in search of Frank Morse.

None of the legislators was in, so the mid-valley activists spent their time chatting up secretaries and aides, passing out copies of testimony to be given in the afternoon hearing and laying the groundwork for future meetings.

At Olson’s office, Johnson and Edie Orner, a retired schoolteacher who heads the Albany chapter of the Archimedes Movement, won a small victory: the promise of a breakfast meeting early next month.

Olson, an Albany Republican, is not known as a supporter of single payer, but he is willing to listen. Orner considers it progress.

“Everything that you do is building momentum,” she said, “and you just have to keep doing what you’re doing and hope that eventually there will be a tipping point.”

Johnson agrees. Like Dembrow, she has no expectations that 3510 will actually pass this session. And like him, she takes the long view of the fight for single payer.

The campaigns for SB 1066 in 1995 and Measure 23 in 2002, she said, started the conversation about single payer in Oregon, and Dembrow’s bill has created the opportunity to take the discussion one step further.

“The world is a different place than it was in 2002 — and I can’t help but think that it’s a different place, at least here in Oregon, in part because of what we did in 2002. We informed a lot of people,” Johnson said.

“That was a building block. This is a building block. And this campaign is not going to die.”

http://www.democratherald.com/news/local/article_38a88e7a-4d46-11e0-9f0e-001cc4c002e0.html

One Payer States conference calls keep movement alive

By BENNETT HALL
Corvallis Gazette-Times, March 12, 2011

It’s 8 o’clock in the morning, and Betty Johnson and Mike Huntington are huddled around a cordless phone set up on a folding table in Johnson’s Corvallis living room. The two veteran health care activists listen intently to the voices coming over the speaker.

A caller from Portland is talking about an upcoming hearing for a single-payer health care bill in the Oregon Legislature.

Someone from Minnesota reports on the prospects for a similar measure there.

A man from Colorado discusses some of the other health care reform bills that are competing with a single-payer plan in his state.

Johnson, who’s been jotting notes on a steno pad, puts down her pen and jumps into the conversation.

“We need to stay on top of the legislature and try to get the best we can out of whatever bill comes out, with the understanding that single payer is what we’ll have eventually,” she suggests. “So we’re on two tracks all the time.”

For almost a year now, scenes like this have been playing out all across the country as health care reformers get together once a week via long distance to compare notes on the fight  in their home states — and to dream of a day when the whole country might be covered by a publicly financed health care program.

The loose-knit coalition — dubbed the One Payer States — sprang from a meeting last April in Wayne, Pa., where single-payer activists had gathered to strategize in advance of a progressive political conference.

Bitterly disappointed in the massive federal health care bill signed just days earlier by President Barack Obama, the participants agreed that the best hope for progress toward single-payer health care now resides with the states. They formed an online discussion group to stay in touch, and soon they were holding conference calls every Friday morning.

The calls have evolved into a lively forum for the U.S. single-payer movement. In addition to providing updates on single-payer legislation (nearly 20 states could consider some variation on the theme this year), callers trade war stories on lobbying lawmakers, swap suggestions on converting skeptics and exchange ideas on everything from mobilizing volunteers to managing donor databases.

The number of participants varies from week to week, as does the topic, but Huntington said he always learns something worthwhile.

“There’s lots of knowledge and not much overhead control,” said the former radiation oncologist, who has devoted himself to health care reform since retiring in 2006.

“We gather the pearls as people mention them from Colorado or Hawaii or Illinois and do what we can with them.”

While the immediate goal of the One Payer States is to promote single-payer bills in individual states, the group has also caught the attention of organizations still working toward a nationwide single-payer system.

Donna Smith, an organizer for National Nurses United, the country’s largest nurses union, was one of the people who helped launch the group, and she’s a regular participant in the weekly calls.

“I think the maximum number of states we’ve had (represented) at any one time is 23 or 24, which is remarkable,” she said. “There are a lot of flowers blooming out there right now.”

Despite the efforts of diehards like Michigan’s John Conyers, who recently reintroduced his Medicare for All bill in the House, single payer has been all but forgotten in Congress. And with President Obama endorsing a move to let states enact their own reforms as early as 2014, many activists believe that’s where change will have to happen.

“There are those who really feel that a state-by-state effort is the way to go,” Smith said.

Mark Almberg, communications director for Physicians for a National Health Program, said state bills help keep single payer in the national health care reform conversation. They also play a crucial educational role, chipping away at some of the lingering objections in the public mind.

“Personally, I view the state single-payer efforts as contributing to the larger goal,” Almberg said.

But he also thinks state-level reforms could serve as a bridge that ultimately leads to a national single-payer health care system.

As an example, he points to Canada. Our neighbor to the north has had a national single-payer health care system since 1984 — but it only came about after each of the country’s 13 provinces and territories passed single-payer plans of their own.

Katie Robbins, a national organizer for Healthcare Now, is hoping the U.S. follows the Canadian template.

It could start with Vermont, where a sympathetic governor and Democratic-leaning legislature just might be on the verge of passing the country’s first true single-payer bill.

If it works there, Robbins said, it could work anywhere.

“I really think that a single-payer system passed at the state level could be a model,” she said.

http://www.democratherald.com/article_0c722690-4d46-11e0-ab28-001cc4c002e0.html

Health Care is a Basic Human Right — Almost Everywhere but Here

By Ronald Pies, M.D.
OpEdNews, March 13, 2011
 
In a recent piece in the Boston Globe, David Abel described a 52-year-old woman named Ona Stewart. Despite being deaf and blind, she is able to live independently, and earn a living by making pottery. Ona Stewart has no family in the area, and relies on a state-funded program that provides aides who help her communicate, shop, and run errands.
 
But now, the proposed Massachusetts budget for 2012 eliminates funding for this program — threatening to leave the DeafBlind Community Access Network high and dry. For people like Ona Stewart, this could mean “dangerous risks to safety,” possible hospitalizations due to failing health, “and institutionalizations,” according to Sharon Applegate, executive director of Deaf, Inc., which oversees the aid program.
 
Ona Stewart’s plight is just one forlorn strand in the unraveling fabric of the American health care system — if “system” is not too generous a term. Despite our tremendous progress in medical research and technological innovation, our health care system is not taking care of those who need it most: the very poor and sick, whose friends, family, or community cannot or will not help them.
 
Far from having “the best health care system in the world” — as some politicians persistently claim — our system is failing in the most basic measures of medical care.   For example, according to a 2002 study by the Institute of Medicine, 18,000 Americans die every year because they don’t have health insurance. And, in a recent Commonwealth Fund-supported study comparing “preventable deaths” in 19 industrialized countries, researchers found that the United States placed last.
 
Our failures in health care are not for lack of spending. As Victor Fuchs, Ph.D., of Stanford University recently noted in the New England Journal of Medicine (Dec. 2, 2010), the U.S. government currently spends more per capita for health care than eight European countries spend from all sources on health care. And yet, life expectancy at birth in every one of these eight countries is higher than that in the U.S. The huge amount of money spent on administrative costs in the U.S. — rather than on direct care — is a major factor in these cross-national disparities.
 
Furthermore, as the Center for Economic and Social Rights notes, “Although the United States offers coverage for the very poorest Americans through Medicaid, this fails to reach millions of Americans who do not qualify as the ‘poorest’ but still have far too little money to afford purchasing their own health insurance and do not have access to it through employment.”
 
Yes, emergency rooms are obligated to provide critical care to all — but poor patients with cancer or chronic renal failure cannot be safely and effectively treated in emergency rooms. And the “free” care provided to indigent patients in the ER simply means that costs are shifted to some other part of the system. The organization Physicians for a National Health Program — consisting of 18,000 physicians, medical students and health professionals — have put the economic issues in a harsh but realistic light:
 
“Sooner rather than later, our nation will have to adopt a single-payer national health insurance program, an improved Medicare for all. Only a single-payer plan can assure truly universal, comprehensive and affordable care to all. By replacing the private insurers with a streamlined system of public financing, our nation could save $400 billion annually in unnecessary, wasteful administrative costs. That’s enough to cover all the uninsured and to upgrade everyone else’s coverage without having to increase overall U.S. health spending by one penny.”
 
That said, the core issue underlying the plight of American health care is not economic, but moral: rather than regarding health care as a basic right, the U.S. sees it as a privilege — one available only to those who can afford it, or who are fortunate enough to have adequate insurance coverage. This view flies in the face of many religious teachings and traditions. Thus, Rabbi Elliot Dorff, a pre-eminent authority on Jewish medical ethics has written:
 
“The fact that more than 40 million Americans have no health insurance is, from a Jewish point of view, an intolerable dereliction of society’s moral duty. The Torah, the Prophets, and the Rabbis of our tradition all loudly proclaim that God commands us to take care of the poor, the starving and the sick. We are duty-bound to find a way for all American citizens to be able to afford health care, for all American citizens.”
 
To be sure, some right-wing Christian groups have castigated health care reform as a betrayal of “God’s plan,” and as an impious embrace of an over-expansive government. Yet the Catholic Church has been unequivocally on the side of health care as a basic human right. Cited in the National Catholic Reporter (9/18/09), Bishop William Murphy, chair of the U.S. Bishops’ Committee on Domestic Justice and Human Development, writes:
 
“Reform efforts must begin with the principle that decent health care is not a privilege, but a right and a requirement to protect the life and dignity of every person. … The bishops’ conference believes health care reform should be truly universal and it should be genuinely affordable” (italics in original).
 
Indeed, the teaching that health care is a right rather than a privilege was articulated by Pope John XXIII in his encyclical, Pacem in Terris (Peace on Earth), published in June 1963.   And just three years later, at a Convention of the Medical Committee for Human Rights held in Chicago, the Rev. Martin Luther King Jr. declared: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
 
Whatever the religious controversies, it is beyond dispute that the U.S. stands virtually alone among wealthy and industrialized nations, in failing to consider health care as a basic right.   Ironically — and some might say, hypocritically — the United States is a signatory to the Universal Declaration of Human Rights, adopted by the General Assembly of the United Nations, and signed by 48 countries. Article 25 of the UDHR stated that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care.”
 
Indeed, in October 2008, President Obama affirmed that health care should be a right, not a privilege, consistent with the principles of the UDHR, as well as with those of Amnesty International and numerous international covenants.
 
Of course, even basic, human rights are not absolute, and health care must be provided in accordance with sound medical judgment and fiscal realities. A right to basic health care means that the government is morally obligated to do all within its means to ensure that medically necessary care is accessible and affordable to all. It does not obligate the government, or physicians, to provide free face-lifts and tummy tucks on demand.
 
Indeed, there is really no such thing as “free” health care; rather, universal health care is made feasible through shared societal responsibility, in the form of a publically financed, single-payer insurance system.
 
It is impossible to “prove” that health care is a basic human right. There is no empirical investigation or experiment that can demonstrate the truth of this claim. Rather, it comes down to the kind of nation and world we wish to live in.
 
As physician and anthropologist Dr. Paul Farmer has said:   “I can’t show you how, exactly, health care is a basic human right. But what I can argue is that no one should have to die of a disease that is treatable.” It is time for the U.S. to embrace Dr. Farmer’s view, and
to enact a health care policy worthy of this country’s highest moral principles.
 
Ronald Pies, M.D., is professor of psychiatry and lecturer on bioethics at SUNY Upstate Medical University, Syracuse, N.Y., and clinical professor of psychiatry at Tufts University School of Medicine in Boston. He is the author of several textbooks, a short story collection, a collection of poems and books on philosophy and ethics.
 
http://www.opednews.com/articles/Health-Care-is-a-Basic-Hum-by-Ronald-Pies-110313-363.html

Privatize Medicare? No thanks!

By Dr. James Mitchiner
AnnArbor.com, March 13, 2011

Well, Karl Rove has done it again. In a recent opinion piece in The Wall Street Journal (“The Politics of Saving ‘Granny,’” Feb. 3), the former Bush presidential adviser sings the praises of replacing traditional Medicare with a federal voucher system.

Under this plan, as proposed by House Budget Committee Chairman Paul Ryan, R-Wis., and former Clinton Budget Director Alice Rivlin, American seniors would receive a federal subsidy to purchase private health insurance policies from competing insurers of their choosing. In other words, Medicare would become privatized, and seniors could select from among hundreds of for-profit commercial or Blue Cross plans across the country, based on their benefit structures, provider networks and premium costs.

Is this a good idea? I think not, for the following three reasons.

The first has to do with the meaning of “choice.” When it comes to choice in health care, I believe that what Americans really want is the ability to choose their own doctors and their own hospitals, rather than their health insurer. In fact, I honestly believe that the average citizen could care less about who their employer’s insurance company is, as long as the ability to pick their own health care providers is preserved.

Under the present system, that is virtually impossible. Most working Americans get their health insurance through their jobs, and their insurance is chosen for them by their employers’ human resources department, generally on the basis of premium cost. And along with that assigned insurer comes a fixed network of providers – doctors, hospitals, outpatient labs, physical therapists, etc. – chosen by their insurer. If a worker chose an out-of-network provider, he/she would have to pay the full cost of seeing that provider, or at least incur a higher co-pay than would be the case if the chosen provider was in-network.

To explore this further, consider how you might currently choose a hospital on the basis of publicly available information. Right now, you can visit the website www.hospitalcompare.hhs.gov and, by typing in your zip code, you can compare up to three local hospitals on the quality of medical care they provide to inpatients with pneumonia, heart attack or congestive heart failure. For each hospital, you can find the typical cost and 30-day mortality rate for each of these diseases. You can also check to see how each hospital performs in preventing surgical infections and blood clots. And you can rank each hospital in terms of creature comforts, like noise level, cleanliness, doctors’ communication skills, and treatment of pain.

All of this is obviously of interest to an educated consumer, and it certainly comports with the public’s desire for more transparency in health care. But here’s the catch: What good does it do for you to know if Hospital A is better than Hospital B, if your insurance plan does not cover the costs if you go to Hospital A (or, if it does, you’d have to pay more out-of-pocket than if you went to Hospital B)? If the purpose of insurance is to limit your out-of-pocket costs for the medical care you value, why should you have to pay more to see a higher quality provider? Clearly, cost is a prime factor in personal healthcare decision-making, even more so for individuals and families of limited financial means. As a practical matter, our current system guarantees that their “choice” will be constrained by the cost of care as seen by their insurer.

The second reason is based on the proposed amount of the Medicare vouchers. Mr. Ryan’s plan, as spelled out in his “Roadmap for America’s Future”, is for those who are now under the age of 55 to receive a payment – as they become Medicare-eligible in 10 years or more – of $11,000, with adjustments for income and disease burden. With the current annual family premium for a private insurance policy averaging $14,000 and climbing, it seems obvious the proposed payment is insufficient for the typical middle-class senior to purchase an insurance policy that would provide meaningful coverage at the time of retirement.

And the third reason for opposing Medicare vouchers is the fact that privatizing Medicare would presumably remove the option of continuing the status quo. As has been the case with attempts to privatize Social Security, there are millions of Americans who prefer government financing of social insurance programs over control by profit-oriented Wall Street firms, thank you very much.

Rather than deconstructing Medicare as we know it, perhaps we should try another tack. Let’s work instead to expand and improve the Medicare we have now, so that everyone – not just seniors – would have access to the health care providers of their choice, without the financial barriers that are characteristic of for-profit health plans. Let’s make health care truly universal, for all people and for all conditions, regardless of where they live, who they work for, or how much they earn.

In other words, let’s cut out the middlemen and their inherent inefficiencies, put people before profits, and push for a single-payer health insurance program instead.

Dr. James C. Mitchiner is an Ann Arbor physician and the former president of the Washtenaw County Medical Society.

http://annarbor.com/news/opinion/privatize-medicare-no-thanks/

Reform stops short of what we need

Letters
Memphis Commercial Appeal, March 13, 2011

As always, I enjoy reading Dr. Manoj Jain’s health care posts in The CA. His March 6 Viewpoint article correctly stated some of the points in the University of Memphis’ study “The Impacts of Health Reform in Shelby County Tennessee.”

Yes, we will be able to expand health insurance coverage to 74,234 non-elderly residents of Shelby County, but 71,200 will be left uninsured. Across Tennessee, 600,000 people will gain access to either private insurance or TennCare when the Patient Protection and Affordable Care Act is fully implemented. These will be modest successes, but should be defended as the best we could get at this time.

As the U of M study notes, however, significant challenges will remain: the inadequate professional work force (doctors and nurses in primary care), the need for continued funding for substantial uncompensated care, the projection of ever-rising health care and insurance costs, reduced private and public payment rates for both health care providers and hospitals, and the strain on state funding for TennCare as more people enter the system. All of these challenges will make our health care market even more complex and dysfunctional.

The U of M study states that PPACA was “health” care reform. It was not. The PPACA law is health “insurance” reform, not meaningful and moral health care reform.

Our health system is really a health care market that is not “free” and has many distortions. PPACA is flawed because it continues our nation’s reliance on an inefficient, wasteful and costly private insurance model of financing health care. Nationally we deny health care access to millions, bankrupt patients and families, ratchet up costs and frustrate efforts to improve quality.

We need a national health program with uniform standards based on medical evidence of best care, plus effective regional planning and implementation so the “challenges” outlined in the U of M study can be overcome.

Physicians for a National Health Program calls for real and sustainable solutions to our health care woes as we work through the political process. PPACA is the law of the land and should not be repealed without anything better to take its place, but it should be superseded in time by quality, affordable care to everyone in our country — single-payer national health insurance, an improved “Medicare for All.”

Dr. Arthur J. Sutherland III
Tennessee coordinator and national board member Physicians for a National Health Program
Memphis

http://www.commercialappeal.com/news/2011/mar/13/letter-reform-stops-short-what-we-need/

Physicians and patients want greater compensation for moving to coordinated care

Swiss Experiment Shows Physicians, Consumers Want Significant Compensation To Embrace Coordinated Care

By Peter Zweifel
Health Affairs
March 2011

Policy makers in several industrial countries are seeking to limit the rise in health care cost growth by supporting coordinated or integrated care programs, which differ from most prevailing forms of medical organization in how physicians are paid and how they work in groups. However, as long as fee-for-service payment systems remain an option, general practitioners will be reluctant to embrace coordinated care because it would give them less autonomy in how they practice. A study in Switzerland indicates that general practitioners will require a pay increase of up to 40 percent before they are willing to accept coordinated care, and a similar study found that Swiss consumers wanted a substantial reduction in premiums to accept it. These findings suggest that provisions of US health care reform designed to encourage the growth of coordinated care — such as accountable care organizations and medical homes — may face a challenging future.

http://content.healthaffairs.org/content/30/3/510.abstract

Comment: 

By Don McCanne, MD

This Swiss discrete choice experiment, evaluating willingness to pay, indicates that both physicians and patients want greater compensation if they are to shift from the traditional fee-for-service arrangement to a coordinated care program.

Although HHS has not yet released the proposed rules for accountable care organizations, they will be coordinated care entities. The release of the regulations has been delayed because of internal disagreements. The question is, will accountable care organizations be such a turnoff that physicians and patients will want to be compensated if they have little choice but to participate in them?

Physicians and patients want greater compensation for moving to coordinated care

Swiss Experiment Shows Physicians, Consumers Want Significant Compensation To Embrace Coordinated Care

By Peter Zweifel
Health Affairs
March 2011

Policy makers in several industrial countries are seeking to limit the rise in health care cost growth by supporting coordinated or integrated care programs, which differ from most prevailing forms of medical organization in how physicians are paid and how they work in groups. However, as long as fee-for-service payment systems remain an option, general practitioners will be reluctant to embrace coordinated care because it would give them less autonomy in how they practice. A study in Switzerland indicates that general practitioners will require a pay increase of up to 40 percent before they are willing to accept coordinated care, and a similar study found that Swiss consumers wanted a substantial reduction in premiums to accept it. These findings suggest that provisions of US health care reform designed to encourage the growth of coordinated care — such as accountable care organizations and medical homes — may face a challenging future.

http://content.healthaffairs.org/content/30/3/510.abstract

This Swiss discrete choice experiment, evaluating willingness to pay, indicates that both physicians and patients want greater compensation if they are to shift from the traditional fee-for-service arrangement to a coordinated care program.

Although HHS has not yet released the proposed rules for accountable care organizations, they will be coordinated care entities. The release of the regulations has been delayed because of internal disagreements. The question is, will accountable care organizations be such a turnoff that physicians and patients will want to be compensated if they have little choice but to participate in them?

Vermont's Struggle for Single-Payer Healthcare

By Steve Early
The Nation, March 10, 2011

After years of political frustration, Earl Mongeon had to see it to believe it. Often, when he finishes his twelve-hour night shift at IBM in Essex Junction, Mongeon heads home for breakfast and a few hours of brush clearing on his sixty-acre lot in Westford. In mid-January, the 55-year-old microprocessor assembler and workers’ rights advocate hopped into his car and drove in the opposite direction, to Montpelier. There, at the state Capitol, Mongeon and other supporters of single-payer healthcare gathered to hear Senators Bernie Sanders and Patrick Leahy, Congressman Peter Welch and new Democratic Governor Peter Shumlin explain that last year’s national healthcare bill — a costly mix of subsidies to private medical plans, some insurance market reforms, Medicaid expansion and a mandate that people buy coverage if they don’t already have it — isn’t good enough for the Green Mountain State. The top state and federal officeholders pledged to work together for something better. “We firmly believe we can be the state that passes the first single-payer system in the country,” Shumlin declared.

Mongeon and other supporters of single-payer have marched and lobbied for years, most recently under the banner of the Vermont Workers’ Center and its “Healthcare Is a Human Right” campaign. Their tireless activism had a lot to do with spurring Vermont’s singular display of independence and political unity. Two weeks earlier, several hundred VWC supporters descended on the legislature on its opening day. State House and Senate leaders, including some recent converts to the single-payer cause, paid fealty to the grassroots movement. Before a boisterous crowd of union members and community activists, 71-year-old Peg Franzen, a VWC leader and disability rights advocate, hailed the “people power” that had persuaded legislators to commission a detailed study of options for universal healthcare last year. In late January a joint session of the Democrat-dominated legislature received a 203-page report from Dr. William Hsiao, the Harvard healthcare economist hired to develop a road map for reform. Hsiao’s research team identified fifteen hurdles to creating the system they recommended: universal coverage with equal access and a common benefit package that includes community-based preventive and primary care, as well as control in the escalation of health costs.

Undaunted by the roadblocks ahead, Shumlin’s special assistant for healthcare, Anya Rader Wallack, went before a joint legislative committee on February 8 to unveil H. 202, “An act relating to a single-payer and unified health system.” Wallack spelled out a three-stage reform process, spanning at least four years but beginning with the creation of a Vermont Health Reform Board to control costs and streamline payment methods. Wallack described Vermont’s current system of multiple private and public payers as “too complex and misguided,” noting that it leaves “more than a quarter of the state’s population potentially facing healthcare bills that send them to bankruptcy.” On behalf of the governor, she insisted that “this craziness must stop. We have to get insurers out of managing medicine and allow providers to use technology and appropriate quality oversight to get waste out of the system.”

The perfect storm for fundamental reform seems to have arrived in America’s second-smallest state, but the wind is blowing rightward elsewhere in the country, with the new Republican majority in the House voting to repeal the Patient Protection and Affordable Care Act, which they brand “Obamacare.” Red-state attorneys general and their GOP governors are challenging the constitutionality of PPACA by focusing on its controversial individual mandate. Healthcare reformers in Vermont aren’t happy with President Obama’s scheme either. That’s why they’re trying to create a social insurance system that would sever the connection between coverage and employment and make access to medical care a “human right” for the state’s more than 625,000 citizens. Marketplace competition and profiteering — given a renewed lease on life nationally by PPACA — would be phased out locally as soon as possible. If single-payer works in Vermont, its backers envision the state becoming the Saskatchewan of America, just as Canada’s thinly populated but left-led prairie province paved the way for Medicare-for-all north of our border fifty years ago.

Getting from here to there will not be easy. The Green Mountain State’s single-payer initiative could be delayed unnecessarily by the implementation timeline of PPACA. Under that law, every state must have health insurance exchanges in order to get the hundreds of millions in new federal dollars to subsidize private benefits. Unless PPACA is amended — as President Obama recommended on February 28 — any pilot projects headed in a single-payer direction would be delayed until 2017. In the now GOP-dominated House, Representative Welch has introduced a bill authorizing the federal waivers needed for Vermont to become “a laboratory for innovation and excellence” in three years, rather than six. As the New York Times reported on March 1, Welch’s bill has “no Republican co-sponsors, making its prospects for passage uncertain at best.”

Single-payer also faces resistance from big business, inside and outside the state. (A taste of that was provided six years ago by antiunion IBM, which held in-plant meetings for 6,000 workers to warn them that a single-payer bill, then pending before the legislature, would require $1 billion in new taxes and force businesses to leave.) A former state legislator from Putney, Governor Shumlin is also part owner of a family business that made him a multi-millionaire. In the face of blunt opposition from his fellow employers, he has pitched single-payer as a way to make Vermont more “business friendly” by curbing healthcare costs, which have doubled in the past decade. Many of the entrepreneurs affiliated with Vermont Businesses for Social Responsibility do seem to favor decoupling health insurance from employment, although not necessarily via a single-payer system. The more mainstream and politically influential Associated Industries of Vermont displays little enthusiasm for moving to a publicly funded plan financed by payroll taxes.

Speaking at a union conference in Burlington over Martin Luther King Day weekend, Mark Dudzic of the Washington, DC–based Labor Campaign for Single Payer Health Care warned about a deluge of anti-single-payer propaganda. “There will be a massive mobilization of corporate power to smash any state single-payer initiative,” he predicted. “Vermont is going to be one of the first battlefields in that fight.” In unionized workplaces — including those represented by the state’s two largest unions, the Vermont Education Association (VEA) and the Vermont State Employees Association (VSEA) — some single-payer advocates worry not enough is being done to educate and mobilize members, whose own negotiated medical benefits are currently at risk. In Vermont, as in other states, there’s growing taxpayer resentment at paying for coverage that most private-sector workers don’t have anymore, whether unionized or not.

At every teachers union bargaining table in Vermont, management is seeking bigger premium contributions, part of a larger giveback trend that has triggered several strike threats. No group of union members has a bigger stake in building a viable tax-supported system of universal coverage than public employees — because their healthcare is already publicly funded by state, county or municipal governments. Nevertheless, as VWC activist and VSEA member Leslie Matthews notes, her own union has not been leading the struggle because some workers are “apprehensive that healthcare reform could lead to erosion of hard-won benefits.” In reality, Matthews arg
ues, “it’s the rising costs, increasing inequities and cost shifts in our current healthcare system that will ultimately bring us down. As union members, our access to affordable healthcare will only be secure when all working people have access to affordable healthcare.”

Workers’ Center director and lead organizer James Haslam does report that the American Federation of Teachers, the Communications Workers of America and the AFL-CIO have all increased their funding of VWC activity. Other national groups, like the Universal Health Care Action Network, have created a “Help Vermont Win! Campaign Fund” to channel more resources into the fight. In late March Physicians for a National Health Program will send nursing and medical students to Vermont to rally support for single-payer. And on May 1 the Jobs with Justice–affiliated VWC will sponsor its biggest May Day “March on Montpelier” ever — to adopt the strongest possible version of Shumlin’s plan.

The new governor’s commitment to the cause is a case study in how Democrats could behave elsewhere — on healthcare and other issues — if their party faced more challenges from the left. Before his run last fall, Shumlin’s only previous bid for statewide office was a failed campaign for lieutenant governor in 2002. His candidacy, as a Democrat, was undermined when 25 percent of the electorate backed Anthony Pollina, a Progressive Party member and longtime single-payer backer who now serves in the State Senate. In last year’s crowded Democratic gubernatorial primary, all the candidates played a game of healthcare reform one-upmanship that helped solidify support for single-payer. Shumlin won the free-for-all by just over 200 votes, even though he was not the preferred nominee of the VEA, VSEA or state AFL-CIO.

In the general election, Shumlin’s opponent was Brian Dubie, an affable Republican who garnered some labor support based on his membership in the Air Line Pilots Association. In the last month of the campaign, the race was very close. That’s when the state’s big-foot independent socialist stepped into the ring. Rallying his own grassroots base, Bernie Sanders held a series of GOTV events for Shumlin that helped the Democratic candidate gain favor among working-class Vermonters who might otherwise have drifted toward Dubie. Shumlin ended up winning by less than 2 percent of the vote.

At a Nation book-signing event in Boston in February, Shumlin’s white-haired, 69-year-old helper was welcomed by local activists. In his discussion with them, Sanders noted that single-payer has become “absolutely mainstream” in Vermont because “we’ve been talking about the issue for thirty years.” But he warned that further grassroots organizing was needed because “this is by no means a done deal.” Back home, the Vermont Workers’ Center and allied groups are taking nothing for granted either, as they gear up for a spring offensive in Montpelier to keep single-payer from getting bogged down in the public policy equivalent of Vermont’s fabled “mud season,” which has never been kind to new models seeking traction, much less the fast track.

This article appeared in the March 28, 2011 edition of The Nation.

http://www.thenation.com/article/159158/vermonts-struggle-single-payer-healthcare

Wis. physician: ‘Gov. Walker, Tear up this bill!’

The following text is an unofficial, slightly edited transcript of a March 5 speech made by Dr. Charles Benedict of Beloit, Wis., to a large crowd outside of the State Capitol in Madison who gathered there to protest Gov. Scott Walker’s budget repair bill. Benedict is a retired neurologist, former representative in the State Assembly and longtime single-payer advocate. He was joined on the speaker’s platform by about 20 colleagues and health professional students.
 
Emcee: Please give a warm welcome to Chuck Benedict and all the medical students who marched here from campus today. [Prolonged cheers.]
 
Dr. Charles Benedict: I hope this is a reinforced platform here. We’ve got a lot of support up here. [Many chants of “Thank you! Thank you!”] Thank all of you.
 
I want to start off by thanking the medical students, some of my colleagues – there are physicians up here, there are nurses up here, there are future physicians, future nurses, health care people, social workers. We’re all banding together in support of the cause up here, which is to – and we usually don’t like to use this word – kill the bill!
 
In fact, I’m finding that this bill makes us ill. (You can see I wasn’t an English major!)
 
I’m up here today mainly because I’m a single-payer advocate, that is, I favor a properly funded Medicare for everybody. I supported single payer long before I ever got into the State Assembly.
 
There is a national group, Physicians for a National Health Program, which has been advocating for this approach to health reform for well over a decade, since the ’90s, maybe even before that – before I was politically aware.
 
We have a strong group here, a strong Wisconsin chapter of Physicians for a National Health Program, the Gene and Linda Farley chapter. And in fact Gene and Linda Farley were mentors of mine in bridging politics and health care. And of course that’s been my passion.
 
For the whole time I was in the State Assembly I was frustrated because we didn’t make as much progress as I would have liked, but at least until this year we did very well. Gov. Jim Doyle did a very good job, getting 98 percent of people covered in this state, with much better health outcomes than almost any other state. So I’m proud of that work.
 
The motto of our state is “Forward.” In my considered opinion, we could best move forward if we had in place a single-payer health care system. We would cut health care costs, we would cover everybody, we would enjoy much better health in general.
 
Unfortunately, that’s not why we’re here right now. We’re here to stop us from going retro, to stop us from going backwards, because part of our new governor’s bill is to undermine and underfund BadgerCare, which has been so good. He wants to make stricter requirements to get on BadgerCare and I think that’s an outrage. There’s so much else in this bill that’s an outrage, but I’ll let other people address that. I’m concerned mostly with the health care issues.
 
I would also like to thank my state senator, Tim Cullen, and his 13 colleagues who are actually sacrificing quite a bit [by staying out of state to deny the Senate a quorum]. They can’t be with their families, but they’re sticking with it and I encourage them.
 
I’ll stop now except for one more thing. What I would like to like to say to Gov. Walker is this: “Gov. Walker, Tear up this bill!”
 
****
 
Related:
PNHP Wisconsin statement on Gov. Scott Walker’s budget bill:
https://pnhp.org/news/2011/march/wis-doctors-group-opposes-governors-budget-bill
 
PNHP’s national statement on the bill:
https://pnhp.org/news/2011/march/wisconsin-battle-crucial-for-health-and-democracy-doctors-group

Conyers Reintroduces HR 676 into the 112th Congress

From All Unions Committee For Single Payer Health Care–HR 676
Press Release, 3/10/2011

On February 11, 2011, Congressman John Conyers, Jr., Democrat of Michigan, reintroduced Expanded and Improved Medicare for All, HR 676, the national single payer health care legislation, into the 112th Congress.  With minor changes, such as the addition of oral surgery to the benefits, HR 676 is the same and will provide all medically necessary care to everyone through progressive public funding and elimination of private health insurance companies.  There are no premiums, no co-pays, no co-insurance, no deductibles.

Congressman Conyers stated:  “Millions of Americans are frustrated with rising health care costs, and have a deep mistrust of private health insurance companies. The for-profit medicine model has resulted in rationed care and created undue stress and financial hardships for millions of Americans across the nation.

“Americans are smart—they know improved Medicare For All works in other countries.  They also know that our own Medicare program, although not perfect, is a proven and efficient method for providing health care to America’s seniors.”

“Improved and Expanded Medicare for All is inevitable in America– it is just a matter of when it will happen. Single-payer health care systems have successfully contained health care costs and provided high quality health care in countries in Europe, Taiwan, Japan, and Canada.  We can no longer continue to embrace the idea that private insurance companies and corporate-owned hospitals and clinics will bring down the costs of health care on their own,” said Conyers.

“It is time for Congress, other elected officials, the medical community, health care policy experts, and the national media to begin to seriously examine how a Medicare For All program in America could contain growing health care costs, and provide quality and affordable health care for all. Our current health care system is simply not financially sustainable over the long run. The time has come for deep systemic change in our health care system, and a large dose of common sense,”  Conyers concluded.

The full legislation is here:
http://thomas.loc.gov/cgi-bin/query/z?c112:H.R.676:

In addition to Conyers, HR 676 currently has 33 co-sponsors who are listed below.  If your Congressperson is listed, please thank him or her.  If not, please call, write, visit your congressperson to persuade him or her to become a co-sponsor of HR 676.

Co-Sponsors of HR 676 as of March 8, 2011:

Rep Baldwin, Tammy [WI-2]
Rep Capuano, Michael E. [MA-8]
Rep Christensen, Donna M. [VI]
Rep Chu, Judy [CA-32]
Rep Cohen, Steve [TN-9]
Rep Davis, Danny K. [IL-7]
Rep Dicks, Norman D. [WA-6]
Rep Doyle, Michael F. [PA-14]
Rep Ellison, Keith [MN-5]
Rep Engel, Eliot L. [NY-17]
Rep Farr, Sam [CA-17]
Rep Filner, Bob [CA-51]
Rep Frank, Barney [MA-4]
Rep Green, Al [TX-9]
Rep Grijalva, Raul M. [AZ-7]
Rep Hinchey, Maurice D. [NY-22]
Rep Jackson, Jesse L., Jr. [IL-2]
Rep Kucinich, Dennis J. [OH-10]
Rep Lee, Barbara [CA-9]
Rep Lofgren, Zoe [CA-16]
Rep Maloney, Carolyn B. [NY-14]
Rep McGovern, James P. [MA-3]
Rep Meeks, Gregory W. [NY-6]
Rep Nadler, Jerrold [NY-8]
Rep Olver, John W. [MA-1]
Rep Pingree, Chellie [ME-1]
Rep Roybal-Allard, Lucille [CA-34]
Rep Scott, Robert C. “Bobby” [VA-3]
Rep Tonko, Paul [NY-21]
Rep Waters, Maxine [CA-35]
Rep Weiner, Anthony D. [NY-9]
Rep Woolsey, Lynn C. [CA-6]
Rep Yarmuth, John A. [KY-3]

HR 676 would institute a single payer health care system by expanding a greatly improved Medicare system to everyone residing in the U. S.

HR 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, and long term care.

HR 676 ends deductibles and co-payments.  HR 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current Congress, HR 676 has 33 co-sponsors in addition to Conyers.

HR 676 has been endorsed by 582 union organizations in 49 states including 136 Central Labor Councils and Area Labor Federations and 39 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NY, NV & MA).

If your union has not yet endorsed HR 676, please do so.  For further information, a list of union endorsers, or a sample endorsement resolution, contact:

http://unionsforsinglepayerHR676.org

Transplant patients a target of Arizona budget cuts

By Tim Gaynor
MSNBC, March 7, 2011

PEORIA, Ariz. (Reuters) — A pacemaker and defibrillator fitted to carpenter Douglas Gravagna’s failing heart makes even rising from the couch of his Phoenix-valley home a battle.

But it is not congestive heart failure that is killing him, he says. It is a decision by Arizona Governor Jan Brewer to stop funding for some organ transplants as the state struggles to reduce a yawning budget deficit.

“She’s signing death warrants — that’s what she’s doing. This is death for me,” says Gravagna, 44, a heavy-set man who takes 14 medications to stay alive.

Gravagna is among 98 people denied state Medicaid funding for potentially life-saving transplants and at the forefront of a harrowing battle over the state’s public finances.

The measure enacted last October by Brewer trimmed spending on Medicaid, the federal-state health insurance program, to help close a projected 2012 budget deficit of $1.15 billion.

It eliminated coverage for transplants including lung, heart, liver and bone marrow after weighing the success and survival rates for certain transplant procedures.

Two patients on the Medicaid waiting list have since died, although it is unclear if transplants would have saved them.

In a statewide speech, the Republican governor singled out the Arizona Health Care Cost Containment System, as the Medicaid program is called in the desert state, as the greatest drain on state coffers.

“At the deficit’s core is the explosive growth in Medicaid spending which, over the last four years, has soared by almost 65 percent and now consumes 29 percent of our state budget,” she said.

“If we are to regain control of state spending, we must reform Medicaid and free Arizona from the fiscal manipulation of the federal government,” Brewer said.

CUTTING RATES TO PROVIDERS

Medicaid, which covers about 60 million Americans — poor adults and children, people who are elderly or have disabilities — is one of the top expenses for states.

It makes up about 16 percent of state budgets, said Judith Solomon at the Center on Budget and Policy Priorities. It pays for more than 40 percent of all births in the United States and is the primary bill-payer for nearly two-thirds of the country’s nursing home residents, according to the Kaiser Family Foundation.

In Texas the proposed budget would cut rates to Medicaid providers, including doctors, dentists, hospitals and nursing homes, by 10 percent, making it more difficult for patients to find health care providers who accept Medicaid.

Other states, among them Nevada, Illinois, Mississippi, Nebraska, Colorado and South Dakota, have also proposed provider rate cuts.

Proposed cuts range from limiting prescription and doctor visits in California to eliminating adult vision and dental services in Georgia, the center says.

Brewer has proposed dropping about 250,000 Arizonans — mostly childless adults — from the program.

Most states are not proposing to trim Medicaid rolls because the new federal health reform law requires that they maintain current Medicaid coverage.

But the U.S. Health and Human Services Department has said Arizona can drop coverage because the state is providing it through a temporary waiver, and the new law does not require extending that.

‘OTHER PLACES TO MAKE CUTS’

Taking an ax to transplant funding is backed by many Republicans in Arizona, some of who sympathize with Brewer.

“It’s a very difficult unenviable position to be in for her,” said Kathy Boatman, a conservative Tea Party activist in the Phoenix valley. “It’s not fun, it’s unpleasant, but when expenses have outpaced income, that’s what you have to do.”

But opponents, including state Democrats, the families of desperately sick patients like Gravagna and some doctors say savings can be made without putting lives on the line.

“There are other places to make cuts. We’ve cut taxes on the very rich, we have corporate tax loopholes,” said Bruce Madison, a doctor who spoke at a rally to restore transplant funding in Phoenix on Saturday.

Madison received a life-saving heart transplant six years ago.

State Representative Anna Tovar, a Democrat and former kindergarten teacher, received two transplants to combat a rare form of leukemia. She says Arizona stands to lose more than $3 million a year in federal matching funds for Medicaid to save $1.4 million a year by restricting transplants.

“When you look at the big scheme of things, saving $1.4 million for 96 lives is not money well spent,” said Tovar, who has introduced four bills seeking to restore Medicaid funding for transplants.

As he grows sicker after being denied a liver transplant last year, Francisco Felix, 32, says any savings from denying him the operation are in some measure a false economy.

“If I got a transplant, I could get back to work … pay my taxes, and help Arizona to get back on its feet,” he said at the rally.

[PNHP note: Dr. George Pauk of Phoenix spoke at the March 5 rally to restore transplant funding on behalf of Physicians for a National Health Program .]

http://www.msnbc.msn.com/id/41928361

Healthcare reform may not reduce number of medical bankruptcies

By: Medical Economics Staff
Medical Economics, March 9, 2011

If Massachusetts’ experience with healthcare reform is any guide, national reform won’t greatly reduce the number of your patients forced into bankruptcy because of their medical bills.

In 2006, Massachusetts became the first state to pass healthcare reform, and its law served as a model for the federal bill passed last year. Supporters said the national Affordable Care Act would result in fewer medical bankruptcies, but that hasn’t been the case in the Bay State, according to a study in this week’s American Journal of Medicine.

The number of medical bankruptcy filings in Massachusetts actually rose from 7,504 in 2007 to 10,093 in 2009, although the share of personal bankruptcies in that state with a medical cause declined from 59.3% to 52.9%, the study found.

Skimpy coverage could be to blame, the study’s authors conclude. “Massachusetts’ health reform, like the national law modeled after it, takes many of the uninsured and makes them underinsured, typically giving them a skimpy, defective private policy that’s like an umbrella that melts in the rain: the protection’s not there when you need it,” writes lead author David Himmelstein, MD, formerly of Harvard Medical School and now a professor of public health at City University of New York.

In 2007, the last year for which national figures are available, medical issues contributed to 62.1% of personal bankruptcies nationally, according to a 2009 study by the same group of researchers. That report found that 77.9% of those bankrupted were insured at the start of their illness.

http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=710974&sk=4b5423422fa09ac28ac70753312be43a