PNHP

PNHP commentary on the Vermont health reform bill

PNHP commentary on the Vermont health reform bill

The Vermont health bill: a brief overview from the single-payer perspective

By Dr. Ida Hellander

This is a two-stage bill which attempts to use the establishment of the required health benefit exchange under PPACA as a bridge to a “public-private single payer health care system” (Green Mountain Care) upon receipt of the required federal waivers. Here are some representative quotes:

“This bill proposes to set forth a strategic plan for creating a single payer and unified health system. It would establish a board …. ; establish a health benefit exchange for Vermont as required under federal health care reform laws; create a public-private single payer health care system to provide coverage for all Vermonters after receipt of federal waivers” (p. 1).

“The intent of the general assembly is to establish the Vermont health benefit exchange in a manner such that it may become the foundation for a single payer system” (p. 5).

“Green Mountain Care shall be implemented upon receipt of a waiver … of the Affordable Care Act. As soon as available under federal law, the secretary of administration shall seek a waiver to allow the state to suspend operation of the Vermont health benefit exchange and to enable Vermont to receive the appropriate federal fund contribution ….” (p. 44).

Comments and concerns

1. The reforms enacted prior to the implementation of single payer are inadequate and delay fundamental reform for 3-6 years. Several states have enacted reforms in the past only to repeal them before full implementation.

2. Provisions necessary for cost-control, such as an annual budget, and separate operating and capital budgets for hospitals, do not appear in the legislation, but do (confusingly) appear in the summary and testimony on the bill by Anya Rader Wallack (summary, p. 3 and testimony, p. 8).

3. The section on pilot projects for payment reform/ACOs appears to allow insurance companies to run ACOs: (p. 15) “the scope of services in any capitated payment should be broad and comprehensive, including prescription drugs, diagnostic services, services received in a hospital, mental health and substance abuse services, and services from a licensed health care practitioner … and may consider “whether to include home health services and long-term care services as part of capitated payments.” Only insurers can bear this much risk, and indeed the three private insurers in Vermont are already involved in developing ACOs.

4. The section on administration allows an insurance company to bid for “administration of certain elements of Green Mountain Care.” This adds unnecessary expense to the program.

5. What will the cost sharing be? (p. 39) “Green Mountain Care shall include cost-sharing and out of pocket limitations as determined by the Vermont health reform board … there shall be a waiver of the cost-sharing requirement for chronic care for individuals participating in chronic care management and for primary and preventive care.” Cost-sharing limits access to care and is ineffective at controlling costs; it should be eliminated.

6. There is no ban on investor-owned health facilities.

7. On the bright side, the single-payer plan includes Medicare and Medicaid (p. 40, 41-42), workers’ compensation and retirees (p.38); covers all “residents” (not just citizens, p. 37); there is at least a nod to the need to have comprehensive benefits including long-term care (if the budget allows); there is language on retraining displaced administrative workers (p. 56); bulk purchasing of drugs and supplies; use of “smart card” technology as in Taiwan (p. 37); and insurance coverage that duplicates the single payer is proscribed (p.41). (This last feature is contradicted, however, by a provision that allows employers to retain their existing coverage.)

8. Some additional features: There is an emphasis on mental health parity and an adequate supply of mental health professionals; emphasis on primary care and use of “medical homes” (this could be good or bad, depending on if they are part of an insurance company-run delivery system).

9. Finally, the bill does not specify financing, except to say that two options will be presented for consideration and all options for raising revenues will be considered (not just a payroll tax, as Dr. William Hsiao had recommended).

Conclusion

Single-payer advocates will have to fight to strengthen the single payer section of this bill, keep single payer in the bill at all (there will likely be attempts to strike it), get the necessary federal waivers and make single payer (aka “Green Mountain Care”) a reality.

Dr. Ida Hellander is executive director of Physicians for a National Health Program.

The Vermont health bill: a brief analysis

By Drs. David Himmelstein and Steffie Woolhandler

The proposed Vermont health reform legislation includes two distinct elements: clear plans to rapidly implement the deeply flawed federal health reform (PPACA) in Vermont; and a vague outline of a single-payer plan that might be implemented six years hence if the feds were to allow it.

In contrast to the bill’s detailed prescription for implementing PPACA, the sections on the single-payer plan leave much to the imagination, punting decisions on critical issues to a board appointed by the governor. It seems that the board is to determine whether critical services like long-term care are included in the benefits package; whether co-payments will be affordable or daunting; how hospitals, home care agencies, nursing homes and doctors will be paid; and whether capital funds are to be allocated separately from operating funds (the sine qua non of effective health planning). And the bill includes no plan for funding the single-payer program.

Happily, the legislation would enroll all Vermont residents (regardless of immigration status) in the single-payer plan. In one critical area the bill seems to come down on both sides of the fence. While it would proscribe the sale of private coverage that duplicates the public plan if the single-payer program is implemented, it would also allow employers to opt out of the plan.

Finally, its uncritical embrace of the latest health policy fad – Accountable Care Organizations (ACOs) – would bols
ter the role of private insurers, at least in the short run. The bill calls for pilot projects in which an ACO would receive capitation payments which would cover all care for a defined population, including long-term care, prescription drugs, etc. Insurers are the only organizations in Vermont with the financial muscle to take on such “full risk” contracts.

In sum, the Vermont bill evidences good intentions and bold promises, but leaves the make-or-break decisions about restructuring health care financing for a later date. This “kick the can down the road” approach is worrisome in a state where the governor and Legislature change every two years, and where multi-stage health reforms have been enacted in the past, only to see the planned reforms abandoned without being implemented. In this context, ongoing mobilization of a broad-based single-payer movement will be critical. Such a mobilization can bolster the governor’s evident enthusiasm for the single-payer project and maintain the courage of the Legislature as they face the inevitable onslaught of corporate opposition to real health care reform.

Drs. Himmelstein and Woolhandler are co-founders of Physicians for a National Health Program.

The Vermont health bill, H. 202: suggested revisions and clarifications

By Vermont Health Care for All members Dr. Deb Richter, Ethan Parke, Marilyn Mode, Ellen Oxfeld and Marjorie Power

The following suggestions have been submitted to members of the Vermont Legislature.

1. Order of elements in bill: Put single payer at the front of the bill – this is the goal. Make clear that the goal is for Green Mountain Care to be up and running as soon as waivers are attained and that the exchanges (the next part of the bill) are an intermediary step that will last only as long and until waivers are obtained.

2. Emphasis: Need stronger language in the single-payer section that the goal is to attain waivers at the earliest date possible. This will also make more political sense, and it will be easier to and simpler to sell to the public.

3. Board: More support staff will be needed for this board. Think about the Public Service Board that has been operating for decades and all the support staff that they have. The consumer rep on the board will be especially in need of support staff because he/she does not already have an association (such as the hospital association) at his or her disposal to help when an issue comes up.

4. What if the federal law is repealed, amended, defunded, or struck down by the U.S. Supreme Court? It should be made clear that Green Mountain Care is contingent on the federal law only to the extent that it might be federally preempted. If the federal law is repealed or changed in such a way that states have more latitude to innovate, then the bill should make clear that we will move more quickly to Green Mountain Care (since no exchange stage would be necessary). H. 202 should also be clear that if the federal government does not fund states under the federal health reform bill, then Vermont must take immediate steps to create a single-payer system with whatever resources are at hand.

5. Principles: Section on principles at the beginning should include health care as a public good as well as health care as a human right.

6. Global budgets: Hospitals should receive global revenue budgets for cost containment and administrative savings. These revenue budgets are not for capital expansion. Hospital capital budgets should be allocated separately from their global revenue budgets. For instance, all things that will generate ongoing operating expenses, such as monies for a new parking lot or an additional MRI scanner, are part of capital budgets and should be allocated separately.

7. Role of for-profit entities: Although we recognize that there are already some for-profit entities within the Vermont health care system, the bill should consider a future moratorium on any for-profit health entities.

Medicare administrative costs – an update

2011 Primer on Medicare Spending and Financing

Kaiser Family Foundation

Administrative Costs

The costs of administering the Medicare program have remained low over the years – less than 2 percent of program expenditures. As such, program administration is not a contributing factor to Medicare’s expenditure growth. Administrative costs include all expenses by government agencies in administering the program (HHS, Treasury, the Social Security Administration, and the Medicare Payment Advisory Commission). Also included are the cost of claims contractors and other costs incurred in the payment of benefits, collection of Medicare taxes, fraud and abuse control activities, various demonstration projects, and building costs associated with program administration.

http://www.kff.org/medicare/7731.cfm

And…

Medicare Administrative Costs Are Higher, Not Lower, Than for Private Insurance

By Robert A. Book, Ph.D.
The Heritage Foundation
June 25, 2009

“The fact is that, in recent years, Medicare administrative costs per beneficiary have substantially exceeded those costs for the private sector, this despite the fact that, as critics note, private insurance is subject to many expenses not incurred by Medicare. Contrary to the claims of public plan advocates, moving millions of Americans from private insurance to a Medicare-like program will result in program administrative costs that are higher per person and higher, not lower, for the nation as a whole.”

http://www.heritage.org/research/reports/2009/06/medicare-administrative-costs-are-higher-not-lower-than-for-private-insurance

The costs of administering the Medicare program remain at less than two percent of program expenditures. Several other reports have been circulated claiming that the administrative costs are much higher. Some of these recalculations add in administrative costs that they claim were excluded from the Medicare numbers, such as the administrative costs of claims contractors, costs of collecting Medicare taxes, and the costs of policing fraud and abuse.

Not only are these costs already included in the “less than two percent” calculation, resulting in true double counting by those challenging the numbers, but the costs they estimate are often pie in the sky, resulting in even greater embellishments of the numbers.

They also play with the numbers, using calculations based on per beneficiary services, or excluding those non-administrative services that the private insurers force on us, and using this as a distraction to dismiss as irrelevant the true percentages paid for administrative services.

Not only do they claim that Medicare administrative costs are understated, they also claim that the true administrative costs of insurers are very close to or even less than their “corrected” Medicare numbers. If that is true, then why have the insurers claimed that they will have difficulty keeping their own administrative costs down to fifteen to twenty percent, a requirement of the Affordable Care Act? And that fifteen to twenty percent doesn’t even include the tremendous administrative burden that they place on the health care delivery system.

So Heritage’s Robert Book claims that a Medicare-like program would result in higher administrative costs for the nation as a whole, than would private insurance.

How do we confront this? Do we simply reply that their circus antics are not credible, and walk away? Or do we simplify our rhetoric and call them what they are – liars? That might not sell well to a public that clings to the lies of the right, while rejecting the process of critical thinking.

Doctors’ group hails reintroduction of Medicare-for-all bill

Single-payer health program would cover all 51 million uninsured, upgrade everyone’s benefits and save $400 billion annually on bureaucracy, physicians say

FOR IMMEDIATE RELEASE
February 15, 2011
 
Contact:
Garrett Adams, M.D., president, Physicians for a National Health Program
Margaret Flowers, M.D., congressional fellow
Quentin Young, M.D., national coordinator, (312) 782-6006
Mark Almberg, communications director, (312) 782-6006,  mark@pnhp.org

A nationwide physicians’ group today hailed the reintroduction of a popular federal bill that would quickly upgrade the Medicare program and expand it to cover the entire population.

The “Expanded and Improved Medicare for All Act,” H.R. 676, sponsored by Rep. John Conyers Jr., D-Mich., would replace today’s private health insurers – and the Obama law’s individual mandate, which is being challenged as unconstitutional – with a single, streamlined public agency that would pay all medical claims, much like Medicare works for seniors today. (See bill summary here.)

“There’s no doubt that expanding Medicare to all is both constitutional and the most cost-effective way to cover everyone,” said Dr. Garrett Adams, president of Physicians for a National Health Program. “A national single-payer program would save over $400 billion a year on bureaucracy and paperwork alone. Plus, it would use proven, effective cost-control techniques like negotiating drug prices and hospital budgets.”
 
“An improved Medicare-for-all program would provide comprehensive coverage to all of the 51 million people who are currently uninsured and enhance the coverage that everyone else has, by eliminating co-pays and deductibles,” Adams said. “It would go far beyond the new health law, which would still leave 23 million people uninsured in 2019.”

“In these difficult economic times, with lack of health coverage leading to thousands of deaths and personal bankruptcies each year, and states struggling to pay the high costs of Medicaid and health coverage for state workers and retirees, everyone’s taking another look at single payer,” he said. “Legislation that could lead to a single-payer plan was just introduced last week in Vermont, led by a push from the governor and a report by Harvard economist William Hsiao that single payer would cover everyone and save the state $490 million in 2015 and at about four times that much by 2024.”

“Surveys have repeatedly shown that about two-thirds of the public supports a Medicare-for-all approach,” Adams said. “And a recent survey of physicians shows that a solid majority now favor government legislation to create national health insurance.”

“As the founder of a free medical clinic in rural Tennessee, I can assure you that the need for fundamental health care reform has never been greater,” he said. “It’s time to stop putting the interests of private insurance companies over patient needs and adopt a single-payer national health program in the U.S.”

*****

Physicians for a National Health Program (www.pnhp.org) is an organization of 18,000 physicians who advocate for single-payer national health insurance, an improved Medicare for all. To speak with a physician/spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

H.R.676 reintroduced in the 112th Congress

112th Congress

The Library of Congress
Thomas

H.R.676

To provide for comprehensive health insurance coverage for all United States residents, improved health care delivery, and for other purposes.

Sponsor: Rep Conyers, John, Jr. [MI-14] (introduced 2/11/2011)

COSPONSORS(25), ALPHABETICAL:
Rep Baldwin, Tammy [WI-2] – 2/11/2011
Rep Capuano, Michael E. [MA-8] – 2/11/2011
Rep Christensen, Donna M. [VI] – 2/11/2011
Rep Chu, Judy [CA-32] – 2/11/2011
Rep Cohen, Steve [TN-9] – 2/11/2011
Rep Dicks, Norman D. [WA-6] – 2/11/2011
Rep Doyle, Michael F. [PA-14] – 2/11/2011
Rep Ellison, Keith [MN-5] – 2/11/2011
Rep Farr, Sam [CA-17] – 2/11/2011
Rep Filner, Bob [CA-51] – 2/11/2011
Rep Frank, Barney [MA-4] – 2/11/2011
Rep Green, Al [TX-9] – 2/11/2011
Rep Grijalva, Raul M. [AZ-7] – 2/11/2011
Rep Hinchey, Maurice D. [NY-22] – 2/11/2011
Rep Jackson, Jesse L., Jr. [IL-2] – 2/11/2011
Rep Lee, Barbara [CA-9] – 2/11/2011
Rep Lofgren, Zoe [CA-16] – 2/11/2011
Rep Maloney, Carolyn B. [NY-14] – 2/11/2011
Rep Meeks, Gregory W. [NY-6] – 2/11/2011
Rep Nadler, Jerrold [NY-8] – 2/11/2011
Rep Pingree, Chellie [ME-1] – 2/11/2011
Rep Roybal-Allard, Lucille [CA-34] – 2/11/2011
Rep Scott, Robert C. “Bobby” [VA-3] – 2/11/2011
Rep Tonko, Paul [NY-21] – 2/11/2011
Rep Weiner, Anthony D. [NY-9] – 2/11/2011

(The text of the bill has not yet been received from the Government Printing Office, but will be posted very soon.)

http://thomas.gov

Comment: 

By Don McCanne, MD

The “Expanded and Improved Medicare for All Act,” H.R. 676, sponsored by Rep. John Conyers Jr., D-Mich., would replace today’s private health insurers – and the Obama law’s individual mandate, which is being challenged as unconstitutional – with a single, streamlined public agency that would pay all medical claims, much like Medicare works for seniors today. (From a PNHP statement to be released later today at www.pnhp.org)

The immediate task for all of us who support an expanded and improved Medicare for all is to begin to recruit more cosponsors. Remind your Representatives that this does not eliminate the important beneficial measures of the Affordable Care Act. What it does instead is it replaces the highly flawed financing structure of ACA with a proven model that both makes health care affordable and includes everyone – the paramount goals of health care reform that have remained elusive until now.

Taiwan's NHI system gets healthier

By Elaine Hou
Taiwan Today, Feb. 11, 2011

Debate has raged for almost a decade over the design of Taiwan’s second-generation National Health Insurance System. The seemingly endless rounds of consultations and negotiations pushed the patience of private and public sector participants to the limit, but their efforts paid handsome dividends Jan. 4 after amendments to the NHI Act passed muster in the Legislature.

Despite some lingering concerns, experts believe the 2G NHI is a fairer, more efficient and financially healthier system.

Launched in 1995, NHI is compulsory social insurance covering more than 99 percent of the nation’s 23 million population. Premium payments are shared by the government, the insured and employers.

Under the amended act, the NHI premium rate for individuals is set at 4.91 percent of their monthly salaries, down from 5.17 percent. A new supplementary premium system will also be in place, charging 2 percent on additional earnings over NT$2,000 (US$69), including interest, professional practice income, rent, stock dividends and bonuses exceeding the equivalent of four months’ wages.

According to former Minister of Health Yaung Chih-liang, the altered premium system will enhance NHI’s finances via the expanded premium base. This approach will also reinforce the ability-to-pay principle and relieve the financial burden on salaried employees, who usually receive little additional income.

“Around 83 percent of the population will pay less,” Yaung said. “Only 17 percent will have increased premiums resulting from extra sources of income.”

“The new plan will generate NT$508.6 billion in health insurance premiums per year, balancing the financial shortfall of the current system in five years,” said Tai Kuei-ying, director-general of the Bureau of National Health Insurance. She added that supplementary payments are estimated to bring in NT$20.8 billion annually.

The system is now in the red for over NT$60 billion, according to the BNHI.

Fu Li-yeh, director of National Yang-Ming University’s Institute of Health and Welfare Policy, described the supplementary premiums as a positive change, though not a perfect solution.

The extra premiums will help realize the core objective of the system’s reform—that those who earn more also pay more, thus making the system fairer from a social standpoint, said Fu, a minister without portfolio from 2004 to 2006.

Responsible for the 2G plan originally submitted to the Legislature, Fu pointed out that as a result of economic development since NHI was implemented, people have more and more supplementary income beyond salaries and wages. “This is especially true for wealthier people.”

She also expressed approval of the integration of the NHI Supervisory Committee and Medical Expenditure Negotiation Committee to form the new NHI Supervisory Commission, a move designed to bring revenues and expenditures more in line.

This body, composed of representatives of the insured, employers, medical service providers, experts in related fields and health care authorities, will be tasked with reviewing issues such as premium rates, the scope of benefits and total yearly payments to contracted medical facilities, the BNHI said.

This change will improve NHI’s financial management, Fu said.

The amended act also stipulates that the commission’s meeting records be made available to the public, and that public opinion be consulted before the government decides on major policies.

“This is an encouraging initiative that will keep information transparent and expand citizen participation,” said Chiang Tung-liang, dean of National Taiwan University’s College of Public Health.

Another improvement with regard to information transparency is the requirement for the public release of NHI financial reports, medical quality ratings of contracted hospitals and major violations by medical facilities.

To ensure quality health care for the entire population, the 2G NHI protects the rights of the disadvantaged via continuous coverage and reduced co-payments, and incorporates convicts into the system.

Meanwhile, the government will cover at least 36 percent of annual premiums, up from 34 percent. “The 2-percent increase is expected to require roughly NT$30 billion in government contributions during the first year of implementing the new system,” the BNHI said.

To prevent abuse of the system, the penalty for fraudulent insurance claims and medical expenses will be increased to up to 20 times the amount illegally received. The current fine is set at twice the illicit gain.

These revisions have received a thumbs up from the Taiwan Healthcare Reform Foundation, an independent, nongovernmental organization promoting the country’s health care quality and patient rights. “We believe they are conducive to a sustainable system, and will unveil a new era for NHI,” the foundation said.

Moreover, the new program will adopt diversified methods of benefit payment to promote illness prevention and the efficient use of resources. These include equal payments for similar diseases or medical treatments, and a capitation fee system.

“Implementation of capitation payment will push physicians to become more proactive in helping people prevent illness, rather than just passively providing medical care to patients,” Fu commented.

Another major amendment to the act requires citizens living overseas for long periods to have been enrolled in NHI over the last two years or to have maintained legal household registration in Taiwan for at least six months before they can enjoy medical care covered by the insurance. In the past, immediate access was granted to those with previous NHI registration or four months of household registration.

“The stricter regulations aim to enhance the system’s fairness,” the BNHI said.

Despite these improvements, the amended act still faces some criticisms, mostly over the new premium base and the unchanged separation of the insured into six categories by occupation, providing the basis for differential premium subsidies from the government.

“The supplementary premiums, which depend mostly on capital gains, seem a less stable source of NHI revenue,” Chiang said. “The amount will go up when the economy is heated and plummet during economic recessions.”

Chu Tzer-ming, former president and chief executive officer of the BNHI, said the six-category structure is a flawed, unfair policy that should be abandoned. “People with the same total income are charged different premiums because they are placed under different categories according to their jobs and vocational status.”

In addition, the policy is inefficient, Fu said. As the categories are based on occupations, when people change careers they may have to drop the insurance and then re-register under a different classification.

“This procedure is unnecessary since these people remain in the same insurance program,” she said.

Fu added that resolving these problems was the major reason for one of the initial 2G NHI proposals—calculating an individual’s insurance fee based on total household income. But this tax-like scheme was roundly rejected in the Legislature due to questions about the rates for the unemployed and those with no income.

Although the outcome is regrettable, Fu said she is still optimistic about the revised act.

“If the supplementary premium system works well, it will encourage future implementation of premium calculations based on household income,” she said.

Cheng Shou-hsia, former director-general of the BNHI, said although the amended bill is not 100-percent perfect, one thing for sure is that the 2G NHI is better than its predecessor. “This should be
acknowledged.”

Despite its problems, Taiwan’s NHI is highly regarded by international experts, Fu said. “I look forward to ongoing improvements to our system.” (THN)

Write to Elaine Hou at elainehou@mail.gio.gov.tw

Excerpted from Taiwan Today: http://www.taiwantoday.tw/ct.asp?xItem=150360&CtNode=428

H.R.676 reintroduced in the 112th Congress

112th Congress

The Library of Congress
Thomas

H.R.676

To provide for comprehensive health insurance coverage for all United States residents, improved health care delivery, and for other purposes.

Sponsor: Rep Conyers, John, Jr. [MI-14] (introduced 2/11/2011)

COSPONSORS(25), ALPHABETICAL:
Rep Baldwin, Tammy [WI-2] – 2/11/2011
Rep Capuano, Michael E. [MA-8] – 2/11/2011
Rep Christensen, Donna M. [VI] – 2/11/2011
Rep Chu, Judy [CA-32] – 2/11/2011
Rep Cohen, Steve [TN-9] – 2/11/2011
Rep Dicks, Norman D. [WA-6] – 2/11/2011
Rep Doyle, Michael F. [PA-14] – 2/11/2011
Rep Ellison, Keith [MN-5] – 2/11/2011
Rep Farr, Sam [CA-17] – 2/11/2011
Rep Filner, Bob [CA-51] – 2/11/2011
Rep Frank, Barney [MA-4] – 2/11/2011
Rep Green, Al [TX-9] – 2/11/2011
Rep Grijalva, Raul M. [AZ-7] – 2/11/2011
Rep Hinchey, Maurice D. [NY-22] – 2/11/2011
Rep Jackson, Jesse L., Jr. [IL-2] – 2/11/2011
Rep Lee, Barbara [CA-9] – 2/11/2011
Rep Lofgren, Zoe [CA-16] – 2/11/2011
Rep Maloney, Carolyn B. [NY-14] – 2/11/2011
Rep Meeks, Gregory W. [NY-6] – 2/11/2011
Rep Nadler, Jerrold [NY-8] – 2/11/2011
Rep Pingree, Chellie [ME-1] – 2/11/2011
Rep Roybal-Allard, Lucille [CA-34] – 2/11/2011
Rep Scott, Robert C. “Bobby” [VA-3] – 2/11/2011
Rep Tonko, Paul [NY-21] – 2/11/2011
Rep Weiner, Anthony D. [NY-9] – 2/11/2011

(The text of the bill has not yet been received from the Government Printing Office, but will be posted very soon.)

http://thomas.gov

The “Expanded and Improved Medicare for All Act,” H.R. 676, sponsored by Rep. John Conyers Jr., D-Mich., would replace today’s private health insurers – and the Obama law’s individual mandate, which is being challenged as unconstitutional – with a single, streamlined public agency that would pay all medical claims, much like Medicare works for seniors today. (From a PNHP statement to be released later today at www.pnhp.org)

The immediate task for all of us who support an expanded and improved Medicare for all is to begin to recruit more cosponsors. Remind your Representatives that this does not eliminate the important beneficial measures of the Affordable Care Act. What it does instead is it replaces the highly flawed financing structure of ACA with a proven model that both makes health care affordable and includes everyone – the paramount goals of health care reform that have remained elusive until now.

Single-payer is still needed to ensure health care for all

By Madeline Zevon
The Journal News (White Plains, N.Y.), Feb. 14, 2011

By 2019, the Patient Protection and Affordable Care Act will improve health-care access by extending health insurance to 32 million more people than are now covered — 16 million through Medicaid starting in 2014, and the rest through subsidies to help lower-income people to afford health insurance.

Although the current legislation extends coverage and institutes reforms of the insurance industry, the League of Women Voters looks at it as only a first step to health-care reform. At its national convention last June, the league reaffirmed its resolution to advocate for single-payer Medicare for all.

Under the PPACA bill, 23 million Americans will still be uninsured in 2019. Surging health-care costs will not be contained. As long as we have private insurers we will never be able to achieve truly universal or affordable care. Compared with other developed nations, the United States pays twice as much for health care and yet ranks 49th among male and female life expectancy. By replacing the inefficient patchwork of private insurers with a streamlined single-payer, our nation can save about $400 billion annually, enough to cover everyone, with no co-pays or deductibles. The House single-payer bill, HR 676, will be introduced again this month. In the 2009-10 Congress, there were 12 co-sponsors from New York, and Nita Lowey, D-Harrison, recently said that when the same bill is reintroduced, she will sign on.

Businesses cannot compete in a global market because, in this country alone, they are saddled with the burden of providing health insurance to their employees. Private for-profit health insurance does not fit the market model.

The good news is that we may not have to wait for national single payer health-care reform. Some states are moving forward on their own. In Vermont, it looks likely to happen soon. Gov. Peter Shumlin is a strong single-payer supporter and Vermont may be the first state to pass it. Vermont has just completed a study showing that nearly a quarter of the current expenditures could be saved through adoption of a single-payer plan. Both houses in California have twice passed single-payer, but it was vetoed by former Gov. Arnold Schwarzenegger. The new governor, Jerry Brown, has supported single-payer in the past. In Hawaii, new Gov. Neil Abercrombie is a supporter of single-payer. In New York, Assemblyman Richard Gottfried, D-Manhattan, is again circulating his bill for single-payer. In Canada, Medicare for all was enacted province by province. Maybe that’s what will happen in our country. It is something to hope for and work for.

The writer is president, League of Women Voters of White Plains.

http://www.lohud.com/article/20110214/OPINION/102140313/1076/OPINION01/Single-payer%20is%20still%20needed%20to%20ensure%20health%20care%20for%20all

The Insurers' Real Agenda for Change

By Wendell Potter
The Huffington Post, Feb. 12, 2011

The media had lots of health care news to obsess about last week. A federal judge ruled the health care reform law unconstitutional, and Senate Republicans tried in vain to repeal the law. But most of the press paid virtually no attention to a potentially much more important development — a multi-pronged effort by five major insurers to strip from the law key regulations and consumer protections that aren’t to their liking.

The insurers do not want the bill repealed or declared unconstitutional. Congress gave them exactly what they wanted by including in the legislation a requirement that all Americans not eligible for Medicare or Medicaid buy coverage from a private insurance company. That provision alone will result in hundreds of billions of dollars in revenue and profits the insurers otherwise would never see.

Officially, the insurers are maintaining neutrality on the court challenges to the law and the repeal efforts. They understand that Republican attorneys general who filed the lawsuits and the Congressional Republicans who voted to repeal the law — most of whom received campaign contributions from the insurers’ political action committees — must go through the motions to satisfy “the base.”

The court challenges and repeal efforts are, in reality, a useful smokescreen for the big insurers, whose real agenda is to gut the law while preserving the mandate. Expect a big lobbying and PR campaign — financed by our insurance premiums — to persuade us that the new regulations and consumer protections will make those premiums skyrocket.

The story much of the press missed was the revelation that the CEOs and lobbyists for the five biggest for-profits — UnitedHealth, WellPoint, Aetna, CIGNA and Humana — have been meeting frequently to plot their attack on the law.

Bloomberg’s Drew Armstrong reported that three committees formed by the group have been meeting almost weekly. While Armstrong didn’t indicate what those committees are doing, I can speculate from previous experience as an insurance company executive that the committees are developing strategies in these areas: lobbying, strategic communications the formation of alliances with other political and business groups and the creation of fake grassroots, or “Astroturf” organizations.

Bloomberg and the the National Journal also reported that the for-profits have solicited proposals from three big PR firms that have done extensive work for the industry: APCO WorldWide, Weber Shandwick and Public Strategies. It sounds familiar. While I was serving as head of corporation communications at CIGNA, I hired APCO and Weber Shandwick to help direct similar efforts and to enhance CIGNA’s reputation.

The for-profits reportedly formed the new coalition — as yet unnamed — because they were upset that America’s Health Insurance Plans (AHIP), their umbrella trade association, had been unsuccessful in keeping the new regulations and consumer protections out of the law in the first place.

So they’re going back to a familiar and successful playbook. Over the past two decades, the big insurers have formed such coalitions to defeat reform initiatives or to persuade the public and lawmakers to see things their way.

When the Clinton reform plan was being debated in 1993 and 1994, Aetna, CIGNA, Prudential and United formed the Alliance for Managed Care (AMC) to argue for a “market-based” solution — managed competition, as it came to be called — as an alternative to broader government involvement in health care. The AMC described itself as “a private-sector approach to health care system reform that uses the marketplace and the power of informed consumer choices to achieve better coverage, while improving quality and cutting costs.”

The AMC later joined a broader coalition that included the U.S. Chamber of Commerce and the National Association of Manufacturers to defeat the Clinton plan.

A few years later, within weeks of being named as defendants in two massive class-action lawsuits, the for-profits formed a new group, America’s Health Insurers (AHI), designed to redirect scrutiny away from them and toward the trial lawyers behind the suits. Attorney Richard “Dickie” Scruggs alone cost the companies billions of dollars in market capitalization when the Wall Street Journal reported on Sept. 31, 1999, that Scruggs was planning to file charges against the insurance firms. On that day, stock prices of Aetna and United alone had plunged nearly 20 percent by the time the closing bell rang at the New York Stock Exchange.

I was CIGNA’s main representative to America’s Health Insurers. My counterparts from other big insurers and I met secretly in hotel conference rooms in Washington and elsewhere with APCO to plan the PR strategy. The idea was to “reframe the debate” — shift attention away from the reasons the insurers were being sued — onerous policies and cheating doctors out of payments — and toward those trial lawyers who were getting filthy rich filing “frivolous” lawsuits. The lawyers — not the insurers — were the real villains. APCO reactivated the front group it had created for the tobacco industry — the Coalition Against Lawsuit Abuse — to generate letters-to-the editor and op-ed pieces in cities where the lawsuits had been filed – particularly Miami, where suits were eventually consolidated. The intent was to influence both the federal judges and potential jurors. (The suits were ultimately settled, with the defendants agreeing to change many of their practices and to pay the plaintiffs hundreds of millions of dollars.)

I was also CIGNA’s representative to yet another organization — the Coalition for Affordable Quality Healthcare (CAQH) — that the big insurers created later. We mounted a huge PR and advertising campaign designed to restore Americans’ faith in managed care, which had taken a beating in the press for such well-publicized practices as “drive-through mastectomies” and “drive-though deliveries.”

So this new grouping is just the latest variant on an oft-used tactic to influence public opinion and public policy. This time, however, the stakes are even higher, for both the insurers and for consumers.

What don’t the companies like? Well, for starters, the rules that now require insurance firms to devote at least 80 percent of what we pay in premiums for actual medical care.

But their sights are also on other provisions of the law that might impair profits. AHIP spokesman Robert Zirklebach provided a glimpse of what insurers really want when he told a reporter last week that industry lobbyists have embarked on a campaign to “educate” members of Congress about ‘flaws’ in the law. For instance, the industry will be trying to persuade lawmakers that young people, many of whom are being charged too much already, will see their premiums go sky high. How do you fix that? The insurers, of course, have an answer: get rid of the requirement that insurers can only sell policies that meet minimum benefit requirements and jettison the prohibition against charging older Americans any more than three times as much as young people. They want to charge them five to ten times as much.

If the latest coalition of big for-profit insurance firms meets its objectives, many of us will eventually be convinced — through sophisticated, behind-the-scenes PR campaigns — that those protections are not in our best interests after all. If those campaigns help the big insurers eliminate such protections, that would be ideal for their bottom lines — but devastating for consumers.

This also appeared on the Center for Public Integrity’s website.

Follow Wendell Potter on Twitter: www.twitter.com/wendellpotter

http://www.
huffingtonpost.com/wendell-potter/the-insurers-real-agenda_b_822356.html

Student rally for single payer, Montpelier, Vt., March 26

Medical students and future health professionals are working to organize a rally in support of single-payer health care in Montpelier, Vermont on Saturday, March 26 sponsored by Physicians for a National Health Program and the American Medical Students Association. 

We are planning a rally of health professionals and students to be held on March 26, 2011 at 1:00 p.m. at the Vermont Statehouse to urge lawmakers to lead the nation by enacting single payer now. Click here for the rally flyer. Our goal is to bring people from the area to show our support for Vermont’s historic effort. We hope that a good turn-out will increase the likelihood of passage of a single-payer bill in Vermont and that coverage of the event will show legislators in other states that health professionals are committed to single-payer.

Schedule of events:
11:30 a.m. – We invite you to join us for a pre-Rally meet-up at the Montpelier High School Cafeteria at 5 High School Drive to make more rally signs and meet other activists.
12:30 p.m. – March to the Statehouse with people from all across the country accompanied by a brass band.
12:45 p.m. – Meet outside the Vermont Statehouse at 115 State St. in Montpelier for photos and chants.  
1 p.m. – Move to the Well of the House for speeches by Sen. Bernie Sanders, Gov. Peter Shumlin, and future physicians, nurses, and health professionals.
2 p.m. – After the rally, we’ll have a quick march through Montpelier
2:20 p.m. – Head back to the Montpelier High School for a catered lunch for everyone’s that’s RSVP’d. There will be plenty of time to talk with single-payer activists, and brief talks by PNHP leaders. We’ll have music throughout the day provided by local musicians.

Please wear your white coat, scrubs, or other professional clothing – and don’t forget to dress warmly! If you have any extra white coats or scrubs, please bring them to loan out to others!

If you have any questions about transportation information from one of our core cities- Boston, Philadelphia, New York City, and Albany, N.Y., please contact Ali Thebert, ali@pnhp.org or call (906) 250-7984.

This issue is important to health professional students as we see how patients are harmed by un-insurance and under-insurance, and we support the model of a system that provides affordable benefits for everyone.

Click here to sign the petition in support of single payer in Vermont.

Please lend a helping hand to medical students and other health professional students by donating to this project today.

Why for-profit health care makes no sense

By James Fieseher, M.D.
Portsmouth (N.H.) Herald, February 09, 2011

One of the major reasons that America is the only industrialized nation with a privatized for-profit health-care system is the fact that most Americans don’t understand how it works. Most of us believe it’s too complicated and doesn’t seem to make sense, even though it’s the only health care that we have ever known. Perhaps the best way to understand how private (non-government) health care works is to apply the concept to a government run service. Try to imagine your local municipality privatizing your police protection:

“9-1-1”

“Yes, I need help. Someone’s downstairs breaking into my house trying to rob me. Please send somebody right away.”

“Can I have your insurance number, sir?”

“My WHAT?”

“Your police insurance number. If you want us to send a policeman over, we’ll have to have your insurance number.”

“But there’s someone in my house now.”

“I’m sorry sir, but without your insurance number I am unable to authorize a patrolman.”

“Okay, let me see if I can find it. I have the lights out and the robber doesn’t know we’re up here.”

“I can wait a short time sir, but I do have other calls.”

“I think I found it. The number is YGG73552W.”

“I’m sorry, sir, but that was last year’s number. You would have been issued a new card for this year. You should have a new card with the last letter Q.”

“Oh here it is. The number is YGG73511Q.”

“Very good, sir. Let me check your number through our system. Please hold just a moment.”

“Please hurry. I think I hear him moving up the stairs.”

“I see from our records sir that your policy doesn’t cover robberies.”

“WHAT?”

“Your policy doesn’t cover robberies, sir. I’m sorry. I won’t be able to send anyone out right now.”

“Look, I’m being robbed. This is the only police policy my employer signed up for. I didn’t even have an option for robbery coverage.”

“I’m sorry sir. You know, you could have purchased an individual coverage policy outside of your employer’s insurance.”

“I can’t afford that. That policy costs over $600 a month!”

“I’m sorry sir. Is there anything else I can help you with this evening?”

“You mean that’s it? That’s all you can do for me?”

“Yes sir.”

“Look, lady. This guy has just broken into my home, he’s now up the stairs and I think he’s about to attack my wife.”

“Oh, that’s good, sir. Your policy covers assault.”

“It does?”

“Of course, sir. That’s part of our personnel protection policy. I also see that you also paid for family coverage, which means that not only are you covered for assault, but your wife and children are covered as well.”

“Thank God! Now, please, send someone over right away!”

“Yes, sir. Would you like us to send a criminal law student, a rookie policeman or a veteran police officer?”

“What kind of ridiculous question is that? Of course I want a veteran police officer. My wife is being attacked!”

“It’s just a matter of co-pay, sir. The generic criminal law student is a $10 co-pay. The rookie will cost you $25 and the veteran police officer is $75.”

“Why so much?”

“That’s what you pay when you want a brand name — our finest.”

“Forget it. I’ve got a handgun somewhere around here. I’m just going to shoot the bastard myself.”

“I wouldn’t do that if I were you, sir.”

“Why not, he’s assaulting my wife.”

“Yes, but shooting him would be an unauthorized, out-of-network referral not to mention our non-compete agreement you signed. We would have to arrest you for that.”

This sounds outlandish, but that’s exactly how private, for-profit health care works. The reason we don’t understand it is exactly because it doesn’t make sense. As a doctor, I’ve spent literally hours on the phone with health insurance representatives in an effort to get needed services for patients with life-endangering illnesses, only to be denied because it wasn’t covered under the patient’s policy.

Of course, there’s the cost factor. Changing from a private health care system to a nonprofit or even a public or single-payer system costs money, quite a bit of money. Take New York City as an example. According to the 2010 budget, New York City spends $4.195 million for “New York’s finest” in police protection, arguably the best police force in the world. That comes to about $500 per person per year for police protection. Not bad. If you or your employer spent that much on health care, it would be quite a bargain for arguably the world’s finest health care. Further, if the police versus medical analogy is continued, we see that privatizing the New York City Police Department would save the taxpayers of New York City $4.195 billion, but it would cost the citizens of New York City a total of between $8 billion and $12 billion for private police protection — based on 2003 world health statistics showing Americans paying two to three times the amount of dollars for health care compared to other industrialized nations. So New York City would save money, but New Yorkers would spend two or three times as much for police protection.

But wait, you say. “We don’t want the government running our health care system.” We don’t? Is there some other government you trust more? You don’t like the way your municipality runs your fire and police departments? Do you really believe that your health insurance company does a better job than your local fire or police department?

The fact is, the better we understand health insurance, the less sense it makes to operate a health care system using a for-profit model. The idea of keeping the government away from health care through privatization or deregulation is akin to keeping the government away from fire or police protection.

America was founded upon principles of capitalism and independence. Changing to a non-profit health care system won’t change that. It will merely make it cheaper for our businesses to run with a healthier population.

The writer is a Portsmouth resident.

http://www.seacoastonline.com/articles/20110209-OPINION-102090351?cid=sitesearch

Brown's dream: deep and accessible care for body and soul

By Susan Dugan
Washington Park (Colo.) Profile, Feb. 10, 2011

Health care activist Roya Brown views health care as a basic human right. Drawn first to Health Care for All Colorado, Brown recently founded Young HCAC, whose mission is to “get young people involved in educating, mobilizing and agitating … to get mad about what is going on.”

“As you become a student of Rumi and learn more about Sufi teaching you learn not to be attached to identities such as where you’re from, what’s your religion, who’s your family. You do not label yourself anymore, in order to become a limitless person.”

Still, she credits her open-minded Iranian family for instilling a thirst for adventure and knowledge. “I was raised in a very outspoken, free-willed family. My father was a lawyer with a knack for humanity and our home was always open to people coming and going. My father was my best friend. The only difference between my dad and me was our spirituality. Inside I knew there had to be something intelligent out there that created the moon and sun and stars. My father was a humanist and realist who believed only in what you could touch and see.”

At age 17, Brown left Tehran for England and majored in math and computer science at Oxford Polytechnic where she met and married her American husband and developed an appreciation for the British health care system. The couple moved to Florida in 1976 where she earned a degree in engineering from the University of Central Florida. “We were going to go back to Iran to see how he liked it and maybe live in both places,” she says.  But the 1979 Iranian revolution squashed those plans. Brown found herself unexpectedly “locked out” and unable to return home for many years.

She worked as an engineer and relocated to Denver in 1983. “Tehran is a high mountain place and Florida was never my cup of tea,” she says. “This was the closest to what I call home.” Again she found work as an engineer but her dissatisfaction with the corporate world continued to escalate. By this time a single mother, she found herself questioning elements of the American dream.

“I wanted to start my own business but couldn’t because of our need for health care. I felt enslaved. I began to see that people here get married because of health care; they have chronic illnesses and can’t get out of their nasty jobs because they can’t get health care. Every time I questioned that, people would come back and say, ‘Well, we don’t want to be socialist.’ And I thought – what’s the difference between working for a corporation for benefits and working for the government who works for the corporation who gives you the benefits? When they talk about a capitalist system they don’t talk about people being entrepreneurs, they talk about a small amount of people in the corporation making a lot of money and the rest of them working for benefits.”

The situation rankled. While continuing to work as an engineer, she began math tutoring at her son’s school and fell in love with teaching. In 1997, she went back to school to earn a math teaching license. Later, she took a part-time position at PS1 Charter School and was offered paid tuition to earn a master’s in special education, a degree she is currently completing.

Meanwhile, in 2003, hoping to show her then 17-year-old son something of the larger world, Brown packed up their bags and hit the road. “I had a couple thousand dollars in my pocket and we went to France for a month and then to England. Everywhere we went, I knew people and we were welcomed.” Her son returned to the States to stay with her mother while Brown took a short-term position in Dubai managing a friend’s engineering company. When Iran was struck by a massive earthquake, Brown traveled there, intending to volunteer for a few weeks before returning to the U.S. but deciding to stay another year to help with rebuilding, working as a construction manager.

Toward the end of her stay, her involvement as a bystander in an accident rekindled an interest in Rumi sparked years earlier. “I had wanted to go see the Rumi celebration in Turkey in December but didn’t really have the money. Then I saw a car accident and jumped out of my car to go help a person lying on the pavement.” As she waited for help, someone stole her purse holding her American and Iranian passports, requiring her to travel to Turkey to receive a new U.S. passport. Inspired by what she learned there about Rumi’s spiritual journey, she returned to the States committed to learn and share more.

At home, she found a dear friend, dying of cancer, who could not afford to purchase her employer-sponsored health care insurance. “When she was diagnosed the insurance company told her she needed to wait because of a pre-existing condition – and public health care told her she needed to wait because she was not poor enough to use the system. By the time I arrived they had already written her off to hospice, because she didn’t have any overnight care. She was crying and asked if I would stay with her. I said, ‘Of course.’”

The friends spent the remainder of her days together, talking, laughing and reviewing their lives. “The only part that bothered me was, why I wasn’t here to fight for her. And then I thought – why should anyone have to fight for health care? At the Democratic National Convention I saw this woman with a sign for Health Care for All Colorado (HCAC) and said, ‘I’ve been looking for you.’”

Brown joined the organization in 2008, participated in planning rallies and served on the board as media chair, all the while filled with a vague longing to do something more. When her college student son asked her to suggest a controversial topic for an English paper he was writing, she recommended health care. “We discussed it while he was doing his first, second and tenth drafts. He did a lot of research looking at different reform options. He ended up getting an A, and said, ‘Now I know what you do, and I am really for what you do.’ And I thought: I didn’t have to twist his arm; he just got it all by himself.”

The experience inspired her to launch Young HCAC. “Our mission is basically to get young people involved in educating, mobilizing and agitating around the whole issue of universal health care in Colorado. We are going to have summit conferences and already have a website to attract young adults. We are hoping to develop a movement through sharing people’s personal stories about failing to access and receive needed health care. I call it a movement because it is not going to happen until people are educated, and get mad about what is going on.”

Currently extending Rumi’s wisdom through “Rumi walk and talks” held in Washington Park and local cafés, Brown’s belief in the power of story to teach and persuade transcends her health care activism. “Rumi was Persian and Persians live on proverbs. One saying we have is, ‘The one who searches will find.’ Rumi changed this around to ‘The one who finds will search.’ What he meant, really, is when you find God, you will search. The searching doesn’t even begin until then. So I guess that since I have found, I have become thirsty for wanting to know more and more, and to share it. This world is not about taking, it is a place to give, to leave your legacy, so you will continue to learn and people will learn from you.”

(Editor’s note: to find out more about Young HCAC, visit YoungHCAC.com.)

http://washingtonparkprofile.com/index.php?option=com_content&task=view&id=1371&Itemid=108

Ezra Klein – Gov. Peter Shumlin: The man who'd bring single-payer health care to Vermont

By Ezra Klein
The Washington Post, 02/10/2011

Peter Shumlin, the newly elected governor of Vermont, has a plan for health-care reform: Rather than repeal it, he wants to supercharge it. His state will set up an exchange, and then, as soon as possible, apply for a waiver that allows it to turn the program into a single-payer system. You can read a summary of the plan here (Word file). I spoke with Shumlin this morning, and a lightly edited transcript of our conversation follows.

Ezra Klein: The report (PDF) prepared by Dr. William Hsiao offered three options for Vermont: single payer, a strong public option and a form of private-public single payer. My understanding is that you’re backing the third option. What separates it from a traditional single-payer system?

Peter Shumlin: Single payer means something different to everyone. The way I define it is that health care is a right and not a privilege. It follows the individual and not the employer. And it’s publicly financed. The only difference between single-payer one and single-payer three in Hsiao’s report is that in single-payer three, the actual adjudication of payment is contracted to an existing insurance entity. So the state doesn’t have to set up a new bureaucracy to run it. His modeling suggests that’d be more economical. It’s a minute difference.

EK: And why go to a single-payer system at all?

PS: In Vermont, this is all about cost containment. There are 625,000 people in Vermont. We were spending $2.5 billion on health care a decade ago. Now we’re above $5 billion. And we project we’ll be spending a billion dollars more in 2014. This is where everyone has failed in health-care reform. And this will go after three of our main drivers of costs.

First, Vermont spends 8 cents on every dollar on administrative costs, just chasing the money around. That’s a huge waste of money. Second, we’ll use technology to conquer waste. You’ll get a Vermont medical card, and everyone’s medical records will be on that card, so you’ll go into a doctor’s office and they’ll know what the last doctor did to you. That helps avoid duplication of services. And the last piece, the most challenging, is remaking the payment system so providers are paid for making you healthy, not for doing the most procedures.

EK: Single-payer systems often lose on the ballot and in the legislature. No state has successfully managed to pass one into law, much less implement it. And the objection that usually stands in the way of these projects is that I’m happy with my health-care insurance, and I don’t trust the government to create something new and put me into it. How do you answer that?

PS: I suspect I’m the only politician in America who won an election in this last cycle with TV ads saying I was going to try to pass the first single-payer system in America. This election was a confirmation of my judgment that Vermonters are tired of enriching pharmaceutical companies and insurers and medical equipment makers at the expense of their family members. The reality in Vermont is that there are not very many Vermonters who are happy with the current system. We’re losing our rural providers. Our small hospitals are struggling. And Vermonters are lowering their coverage and paying more and more for it.

EK: How will the funding work? Right now, a lot of money comes from employers. What happens to their share?

PS: Where health care has failed is in designing a cost containment mechanism that works. That’s the really hard part of our job. So I’m asking us to spend the next 12 months designing the tools for cost containment. Once we do, we’ll figure out how to structure the way we pay for it.

EK: One of the things you asked of Dr. Hsiao was to preserve provider incomes. How can you do that while cutting costs? At some point, doesn’t lower spending also mean fewer doctors or hospitals or lower incomes?

PS: The reason Vermont has the opportunity to be the lab for a different kind of change is that we don’t have a lot of high-paid physicians in Vermont. We have a lot of low-paid physicians. We have rural providers who’re making less than they did when they graduated from medical school. Our cost driver is not that we have a lot of physicians running around in Mercedes-Benzes. It’s waste in the system.

EK: How will this interact with other systems? Let’s say I have Kaiser Permanente. I come to Vermont and break my leg. What happens?

PS: Nothing different than what happens right now. You’d go to one of our providers’ offices, and they’d bill Kaiser for that one. No different than if you break a leg in France or Switzerland. Radical as this seems to Americans, the rest of the world has figured this out and gotten it right. We keep getting it wrong, and we’re paying for it.

http://voices.washingtonpost.com/ezra-klein/2011/02/gov_peter_shumlin_the_man_whod.html