Coburn: Private health insurance may end soon

By Randy Krehbiel
Tulsa World
October 12, 2010

“There will be no insurance industry left in three years,” Coburn told the Republican Women’s Club of Tulsa County.

“That is by design. You’re going to make insurance unaffordable for everyone — which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run, single-payer health care.”

http://www.tulsaworld.com/news/article.aspx?subjectid=262&articleid=20101012_262_0_hrimgs995333

Senator Tom Coburn, M.D.
http://coburn.senate.gov/public/

And…

Nursing Economics: Is U.S. Health Care Evolving Toward a Single-Payer System? An Interview with Health Care Economist Paul Feldstein, PhD

Interview by Peter I. Buerhaus, PhD, RN, FAAN
Medscape Family Medicine
October 13, 2010

Peter Buerhaus: Looking to the future, do you think the passage of health reform legislation and its implementation could eventually lead to the adoption of a single-payer system?

Paul Feldstein: It is hard to say where we are going, particularly because the legislation creates health insurance exchanges which will be overseen by an insurance regulator. The insurance regulator will have the authority to set the benefit package and influence whether a state approves or denies rate hikes by insurance companies. I can see a scenario where there is very little cost containment and little pressure to keep insurance premiums from rising substantially. And, if there is a weak mandate for individuals to purchase health insurance, then the resulting adverse selection is likely to cause insurers to increase their premiums. People will become dissatisfied with the premium increases and some may become more supportive of a government-funded public insurance option. By heavily subsidizing government-provided health insurance and undercutting private insurers, many people will switch to lower-cost public insurers because studies show that people are willing to switch insurers for not much of a price difference. Eventually, if many individuals purchase public insurance, we could end up with a single-payer system or something close to one.

http://www.medscape.com/viewarticle/726680_5

Paul J. Feldstein, Ph.D.
http://merage.uci.edu/Faculty/FacultyDirectory/FacultyProfiles.aspx?FacultyID=18

The majority of progressives predict that a single payer system is inevitable because the nation will no longer tolerate the increasing costs of health care. On the other side, many conservatives and libertarians predict that a single payer system may be inevitable because health plans will no longer be affordable in a regulated insurance market. Senator Tom Coburn and Professor Paul Feldstein represent the latter view.

Senator Coburn has been nicknamed “Dr. No” because of his conservative, anti-government, obstructionist approach to legislation. His views can be dismissed as those of a right-wing ideologue.

Prof. Feldstein, on the other hand, presents a more intellectual discourse of his position on health care financing. In a conversation we had during a forum at which we both appeared (Eighth Tamkin Symposium at the University of California at Irvine), Prof. Feldstein indicated to me that he was a dedicated follower of the teachings of his mentor at the University of Chicago – Milton Friedman. I probably need not say more.

The full interview of Prof. Feldstein (link above) is worth reading if you wish to better understand the sincere framing of single payer concepts from the perspective of a free-market intellectual. Although I say that his framing is sincere, it is distorted by what I believe to be exaggerated potential adverse consequences of single payer and by his failure to include certain inescapable benefits of single payer which, specifically, more than offset the deficiencies. He also repeats many of the trite criticisms of single payer that are based more on ideology and less on solid policy science, supposedly proving points by citing what are actually exceptions.

So while those on the right threaten us with the inevitability of single payer, the supporters of health care justice preach the inevitability of single payer. It looks like it’s not if we’ll have single payer, but when. But it won’t happen until we all understand that the financing mechanism of the Patient Protection and Affordable Care Act is not an avenue to reform, but a barrier that must be displaced. What we put in its place is where we totally disagree.

I might add that my conversation with Prof. Feldstein was in 2006, long before the recent reform process was underway, and at that time he told me that he believed that eventually we would have a single payer system, as much as he lamented the prospect. He is a very bright individual.

Wolters Kluwer Pharma Solutions

Sample represents more than 80% of the dispensing activity within the United States for retail prescriptions, inclusive of largest retail chains.

While payers still greatly influence patient access to treatment, increasingly, patients are weighing treatment cost and benefit, especially of new prescriptions.

2009: Commercial Rx Claims – New Rx

85.59% – Dispensed to patient
8.08% – Denied by health plans
6.33% – Abandoned by patients
Brand Rx – 9.30% abandoned
Generic Rx – 5.50% abandoned

http://www.wolterskluwerpharma.com/Press/Pharma%20Insight%202009%20-%20Media.pdf

Comment: 

By Don McCanne, MD

This study covered 80 percent of the retail dispensing activity within the United States. It included patients for whom our health care system is working, at least theoretically. These individuals gained access to a physician, received one or more prescriptions, and then attempted to have the prescription filled by a retail pharmacy.

Private health plans that should be assisting patients in receiving the care that they should have, denied over 8 percent of the new prescriptions recommended by physicians.

Of all new prescriptions, over 6 percent were prepared but then abandoned by patients, primarily because of the high out-of-pocket costs of the prescription.

We need a health care system that ensures that all of us receive the health care that we need, including prescription drugs. A single payer national health program – an improved Medicare for all – would do just that. No one would walk away from a pharmacy empty handed.

Pharma Insight 2009

Wolters Kluwer Pharma Solutions

Sample represents more than 80% of the dispensing activity within the United States for retail prescriptions, inclusive of largest retail chains.

While payers still greatly influence patient access to treatment, increasingly, patients are weighing treatment cost and benefit, especially of new prescriptions.

2009: Commercial Rx Claims – New Rx

85.59% – Dispensed to patient
8.08% – Denied by health plans
6.33% – Abandoned by patients
Brand Rx – 9.30% abandoned
Generic Rx – 5.50% abandoned

http://www.wolterskluwerpharma.com/Press/Pharma%20Insight%202009%20-%20Media.pdf

This study covered 80 percent of the retail dispensing activity within the United States. It included patients for whom our health care system is working, at least theoretically. These individuals gained access to a physician, received one or more prescriptions, and then attempted to have the prescription filled by a retail pharmacy.

Private health plans that should be assisting patients in receiving the care that they should have, denied over 8 percent of the new prescriptions recommended by physicians.

Of all new prescriptions, over 6 percent were prepared but then abandoned by patients, primarily because of the high out-of-pocket costs of the prescription.

We need a health care system that ensures that all of us receive the health care that we need, including prescription drugs. A single payer national health program – an improved Medicare for all – would do just that. No one would walk away from a pharmacy empty handed.

World Health Organization
(Accessed October 11, 2010)

Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved. Infant, maternal and under-five mortality rates have all decreased over the last decades, with a marked increase in life expectancy at birth.

Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. The public sector is largely used for in-patient and preventive care while the private sector is used mainly for outpatient curative care.

The Public Sector

The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a health-care hub. These Units have both in- and out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC Units have a package service called “comprehensive emergency obstetric care services” (EOC) available, with an expert gynaecologist, an anaesthetist and skilled support nurses on duty round-the-clock, and basic laboratory facilities. At a lower tier, the Union Health and Family Welfare Centre (UHFWC) are operational, constituted with two or three sub centers at the lowest administrative level, and a network of field-based functionaries. The public sector field-level personnel are comprised of Health Assistants (HAs) in each union who supposedly make home visits every two months for preventive healthcare services, and Family Welfare Assistants (FWAs) who supply condoms and contraceptives pills during home visits. Recently some of the female HAs and FWAs have been trained as birth attendants (skilled birth attendants – SBAs), to provide skilled services within a household setting.

The Private Sector

In the private sector, there are traditional healers (Kabiraj, totka, and faith healers like pir / fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/ Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand. In addition to dispensing medicine, sellers at these mostly unlicensed and unregulated retail outlets also diagnose and treat illnesses despite having no formal professional training.

http://www.whoban.org/health_system_bangladesh.html

And…

Physician’s obligations to patients

By Dr. Delwar Hossain
The New Nation – Bangladesh’s Independent News Source
October 10, 2010

Doctors of medical background are usually brilliant and talented groups of people of our country. They are the cream of the society and pride of this country.

High moral values and strict ethical practice should be observed in the physicians simply because they are considered next to Allah by the sick people. In true sense they are the deputy of almighty Allah in this world. Unfortunately with the few exceptions they are indulged in immoral activities and unethical practices of all sorts. I think it is not too late to rectify ourselves now.

Malpractices of all sorts have engulfed the physicians of all categories and money appears as the single most important driving factor. Money is an important factor but should not be the only factor for our profession.

Cesarean operation is a life saving method for mother and baby. It was invented only for selective and complicated labor. It is still used as such in the West. But quite different picture is seen in our country. When this facility was first available in our country several decades ago hardly 10% labor was done by it. It was used only in cases of its valid indications. But now around 50% (varies 40% to 95%) labors are done by it across the country and in majority cases injudiciously. It becomes the easiest method of earning a lot of money within shortest possible time! If we become an exploiter instead of a perfect technical person how can we be able to protect the interest of a patient?

Cases of gross negligence on the part of physicians are being reported in paper now and then. These are nothing but the tip of the ice-burg only. One of my known persons decided to deliver their baby by Cesarean section. He managed to get the best anesthesiologist and gynecologist. Patient started muscle twitching on the operation table during later part of operation. On inquiry it was found that Oxygen cylinder ran out of oxygen! And the anesthetist was found upstairs in computer game! By this time patient incurred irreparable brain damage. Then she was transferred to Dhaka to Singapore and attended by both the British and the American specialists. But did not get any benefit. Now she is deeply unconscious, has been bed-ridden for last one and a half decades, on life saving measures. She and her family life had gone to hell.

http://nation.ittefaq.com/issues/2010/10/10/news0680.htm

Comment: 

By Don McCanne, MD

Can a health care system in a transitional society such as Bangladesh provide lessons for a modern industrialized nation like the United States? Well, yes. See how many lessons you can find here.

Health System in Bangladesh

World Health Organization
(Accessed October 11, 2010)

Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. This country has made important gains in providing primary health care since the Alma Ata Declaration in 1978. All health indicators show steady gains and the health status of the population has improved. Infant, maternal and under-five mortality rates have all decreased over the last decades, with a marked increase in life expectancy at birth.

Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. The public sector is largely used for in-patient and preventive care while the private sector is used mainly for outpatient curative care.

The Public Sector

The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a health-care hub. These Units have both in- and out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC Units have a package service called “comprehensive emergency obstetric care services” (EOC) available, with an expert gynaecologist, an anaesthetist and skilled support nurses on duty round-the-clock, and basic laboratory facilities. At a lower tier, the Union Health and Family Welfare Centre (UHFWC) are operational, constituted with two or three sub centers at the lowest administrative level, and a network of field-based functionaries. The public sector field-level personnel are comprised of Health Assistants (HAs) in each union who supposedly make home visits every two months for preventive healthcare services, and Family Welfare Assistants (FWAs) who supply condoms and contraceptives pills during home visits. Recently some of the female HAs and FWAs have been trained as birth attendants (skilled birth attendants – SBAs), to provide skilled services within a household setting.

The Private Sector

In the private sector, there are traditional healers (Kabiraj, totka, and faith healers like pir / fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/ Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand. In addition to dispensing medicine, sellers at these mostly unlicensed and unregulated retail outlets also diagnose and treat illnesses despite having no formal professional training.

http://www.whoban.org/health_system_bangladesh.html

And…

Physician’s obligations to patients

By Dr. Delwar Hossain
The New Nation – Bangladesh’s Independent News Source
October 10, 2010

Doctors of medical background are usually brilliant and talented groups of people of our country. They are the cream of the society and pride of this country.

High moral values and strict ethical practice should be observed in the physicians simply because they are considered next to Allah by the sick people. In true sense they are the deputy of almighty Allah in this world. Unfortunately with the few exceptions they are indulged in immoral activities and unethical practices of all sorts. I think it is not too late to rectify ourselves now.

Malpractices of all sorts have engulfed the physicians of all categories and money appears as the single most important driving factor. Money is an important factor but should not be the only factor for our profession.

Cesarean operation is a life saving method for mother and baby. It was invented only for selective and complicated labor. It is still used as such in the West. But quite different picture is seen in our country. When this facility was first available in our country several decades ago hardly 10% labor was done by it. It was used only in cases of its valid indications. But now around 50% (varies 40% to 95%) labors are done by it across the country and in majority cases injudiciously. It becomes the easiest method of earning a lot of money within shortest possible time! If we become an exploiter instead of a perfect technical person how can we be able to protect the interest of a patient?

Cases of gross negligence on the part of physicians are being reported in paper now and then. These are nothing but the tip of the ice-burg only. One of my known persons decided to deliver their baby by Cesarean section. He managed to get the best anesthesiologist and gynecologist. Patient started muscle twitching on the operation table during later part of operation. On inquiry it was found that Oxygen cylinder ran out of oxygen! And the anesthetist was found upstairs in computer game! By this time patient incurred irreparable brain damage. Then she was transferred to Dhaka to Singapore and attended by both the British and the American specialists. But did not get any benefit. Now she is deeply unconscious, has been bed-ridden for last one and a half decades, on life saving measures. She and her family life had gone to hell.

http://nation.ittefaq.com/issues/2010/10/10/news0680.htm

Can a health care system in a transitional society such as Bangladesh provide lessons for a modern industrialized nation like the United States? Well, yes. See how many lessons you can find here.

By Robert B. Reich
Published 2010 by Alfred A. Knopf

Introduction

In September 2009… Treasury Secretary Tim Geithner, assessing what had happened to the United States in the years leading up to the Great Recession, repeated the conventional view that “for too long, Americans were buying too much and saving too little.”

The problem was not that Americans spent beyond their means but that their means had not kept up with what the larger economy could and should have been able to provide them.

Part I – The Broken Bargain
Chapter 2 – Parallels

Economists Emmanuel Saez and Thomas Piketty have examined tax records extending back to 1913. They discovered an interesting pattern. The share of total income going to the richest 1 percent of Americans peaked in both 1928 and in 2007, at over 23 percent.

Between the two peaks is a long, deep valley. After 1928, the share of national income going to the top 1 percent steadily declined… to 9 to 11 percent in the 1950s and 1960s, finally reaching the valley floor of 8 to 9 percent in the 1970s. After this, the share going to the richest 1 percent began to climb again… reaching its next peak of more than 23 percent in 2007.

Part III – The Bargain Restored
Chapter 1 – What Should Be Done: A New Deal for the Middle Class

Medicare for all. The passage of health care legislation in 2010 represents only the first step toward reform. The next stage should be Medicare for all. The most efficient way to provide all Americans with high-quality health care is to allow everyone to sign up for Medicare and to subsidize the costs for middle-class and lower-income families.

http://www.randomhouse.com/catalog/display.pperl/9780307592811.html

Emmanuel Saez – Striking it Richer: The Evolution of Top Incomes in the United States
http://elsa.berkeley.edu/~saez/saez-UStopincomes-2008.pdf

Comment: 

By Don McCanne, MD

The landmark study by Emmanuel Saez and Thomas Piketty has been cited by many in helping to explain what went wrong with our economy. The productivity gains of American workers were not shared with the workers but were transferred to the wealthiest Americans. Robert Reich explains that the economy falters when the masses to not have the funds to purchase the products and services made possible by their own productivity.

What should be done is intuitive. In restoring the bargain by creating a New Deal for the middle class, one of the most obvious and effective measures would be to establish a Medicare program for everyone and fund it publicly through progressive tax policies.

So simple and so right. Yes, Reich is right.

Aftershock

By Robert B. Reich
Published 2010 by Alfred A. Knopf

Introduction

In September 2009… Treasury Secretary Tim Geithner, assessing what had happened to the United States in the years leading up to the Great Recession, repeated the conventional view that “for too long, Americans were buying too much and saving too little.”

The problem was not that Americans spent beyond their means but that their means had not kept up with what the larger economy could and should have been able to provide them.

Part I – The Broken Bargain
Chapter 2 – Parallels

Economists Emmanuel Saez and Thomas Piketty have examined tax records extending back to 1913. They discovered an interesting pattern. The share of total income going to the richest 1 percent of Americans peaked in both 1928 and in 2007, at over 23 percent.

Between the two peaks is a long, deep valley. After 1928, the share of national income going to the top 1 percent steadily declined… to 9 to 11 percent in the 1950s and 1960s, finally reaching the valley floor of 8 to 9 percent in the 1970s. After this, the share going to the richest 1 percent began to climb again… reaching its next peak of more than 23 percent in 2007.

Part III – The Bargain Restored
Chapter 1 – What Should Be Done: A New Deal for the Middle Class

Medicare for all. The passage of health care legislation in 2010 represents only the first step toward reform. The next stage should be Medicare for all. The most efficient way to provide all Americans with high-quality health care is to allow everyone to sign up for Medicare and to subsidize the costs for middle-class and lower-income families.

http://www.randomhouse.com/catalog/display.pperl/9780307592811.html

Emmanuel Saez – Striking it Richer: The Evolution of Top Incomes in the United States
http://elsa.berkeley.edu/~saez/saez-UStopincomes-2008.pdf

The landmark study by Emmanuel Saez and Thomas Piketty has been cited by many in helping to explain what went wrong with our economy. The productivity gains of American workers were not shared with the workers but were transferred to the wealthiest Americans. Robert Reich explains that the economy falters when the masses to not have the funds to purchase the products and services made possible by their own productivity.

What should be done is intuitive. In restoring the bargain by creating a New Deal for the middle class, one of the most obvious and effective measures would be to establish a Medicare program for everyone and fund it publicly through progressive tax policies.

So simple and so right. Yes, Reich is right.

By Peter A. Muennig and Sherry A. Glied
Health Affairs
October 7, 2010

Many advocates of US health reform point to the nation’s relatively low life-expectancy rankings as evidence that the health care system is performing poorly. Others say that poor US health outcomes are largely due not to health care but to high rates of smoking, obesity, traffic fatalities, and homicides. We used cross-national data on the fifteen-year survival of men and women over three decades to examine the validity of these arguments. We found that the risk profiles of Americans generally improved relative to those for citizens of many other nations, but Americans’ relative fifteen-year survival has nevertheless been declining. For example, by 2005, fifteen-year survival rates for forty-five-year-old US white women were lower than in twelve comparison countries with populations of at least seven million and per capita gross domestic product (GDP) of at least 60 percent of US per capita GDP in 1975. The findings undercut critics who might argue that the US health care system is not in need of major changes.

We speculate that the nature of our health care system — specifically, its reliance on unregulated fee-for-service and specialty care — may explain both the increased spending and the relative deterioration in survival that we observed. If so, meaningful reform may not only save money over the long term, it may also save lives.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0073v1

Comment: 

By Don McCanne, MD

This study provides credible evidence that lower life expectancy in the United States, when compared to twelve other nations, is not due to smoking, obesity, traffic accidents nor homicides. Thus this study can be used to refute those who contend that we have the greatest health care system on earth, but it is the bad habits of those unworthy of health care that result in our lower life-expectancy ratings.

The authors speculate, “It is possible that rising US health spending is itself responsible for the observed relative decline in survival.” Specifically they suggest that “reliance on unregulated fee-for-service and specialty care may explain both the increased spending and the relative deterioration in survival.” They seem to dismiss the lack of health insurance as not having been found to have “substantial impacts,” though there is “uncertainty on this point.”

This opinion meshes well with a prevalent view expounded during the reform process that our costs are high because of an excess of health services that often impair outcomes. With almost no substantial evidence, the Dartmouth variations often were blamed for impaired outcomes, while largely ignoring a plethora of data that show that insufficient care, especially related to being uninsured or under-insured, greatly impairs outcomes.

One of the authors of this study, Sherry Glied, is taking this spending-causes-decline-in-survival theory with her to the Department of Health and Human Services where she is assistant secretary for planning and evaluation. These “neo-theorists” preach that we can improve quality and decrease spending through economic tools such as accountable care organizations and bundling of services. Come on.

It’s time to bring in the old school European-style theorists who have already shown that universal social insurance programs with well established primary care infrastructures do control costs and improve outcomes. Many Europeans engage in the same bad habits as found here in the United States, yet none of them are unworthy of health care.

What Changes In Survival Rates Tell Us About US Health Care

By Peter A. Muennig and Sherry A. Glied
Health Affairs
October 7, 2010

Many advocates of US health reform point to the nation’s relatively low life-expectancy rankings as evidence that the health care system is performing poorly. Others say that poor US health outcomes are largely due not to health care but to high rates of smoking, obesity, traffic fatalities, and homicides. We used cross-national data on the fifteen-year survival of men and women over three decades to examine the validity of these arguments. We found that the risk profiles of Americans generally improved relative to those for citizens of many other nations, but Americans’ relative fifteen-year survival has nevertheless been declining. For example, by 2005, fifteen-year survival rates for forty-five-year-old US white women were lower than in twelve comparison countries with populations of at least seven million and per capita gross domestic product (GDP) of at least 60 percent of US per capita GDP in 1975. The findings undercut critics who might argue that the US health care system is not in need of major changes.

We speculate that the nature of our health care system — specifically, its reliance on unregulated fee-for-service and specialty care — may explain both the increased spending and the relative deterioration in survival that we observed. If so, meaningful reform may not only save money over the long term, it may also save lives.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0073v1

This study provides credible evidence that lower life expectancy in the United States, when compared to twelve other nations, is not due to smoking, obesity, traffic accidents nor homicides. Thus this study can be used to refute those who contend that we have the greatest health care system on earth, but it is the bad habits of those unworthy of health care that result in our lower life-expectancy ratings.

The authors speculate, “It is possible that rising US health spending is itself responsible for the observed relative decline in survival.” Specifically they suggest that “reliance on unregulated fee-for-service and specialty care may explain both the increased spending and the relative deterioration in survival.” They seem to dismiss the lack of health insurance as not having been found to have “substantial impacts,” though there is “uncertainty on this point.”

This opinion meshes well with a prevalent view expounded during the reform process that our costs are high because of an excess of health services that often impair outcomes. With almost no substantial evidence, the Dartmouth variations often were blamed for impaired outcomes, while largely ignoring a plethora of data that show that insufficient care, especially related to being uninsured or under-insured, greatly impairs outcomes.

One of the authors of this study, Sherry Glied, is taking this spending-causes-decline-in-survival theory with her to the Department of Health and Human Services where she is assistant secretary for planning and evaluation. These “neo-theorists” preach that we can improve quality and decrease spending through economic tools such as accountable care organizations and bundling of services. Come on.

It’s time to bring in the old school European-style theorists who have already shown that universal social insurance programs with well established primary care infrastructures do control costs and improve outcomes. Many Europeans engage in the same bad habits as found here in the United States, yet none of them are unworthy of health care.