C-SPAN
Wednesday Dec. 16, 2009
Senator Bernard Sanders (I-VT) made remarks after withdrawing his single payer amendment from consideration on the Floor of the Senate.
Testimony of Dr. Dwight Michael before the Pennsylvania Senate Banking and Insurance Committee
12/16/2009
Good morning Chairman White and distinguished members of the Senate Banking and Insurance Committee.
I am Dwight Michael, a Family Physician.
I am here to share my reformed and informed belief that Senate Bill 400 is by far the best way to provide high-quality, affordable, accessible healthcare to all PennsyIvanians at a cost to practically all of us that is less than what we currently pay.
I am in my 25th year of practice in Gettysburg, Pa. Our group of 5 family physicians is independent. I am a Republican and have been fairly conservative in my views over the years. I formulate my own opinions based on my research and my experiences.
I have been asked to focus my comments on why SB 400 is beneficial to physicians.
First, SB 400 will allow physicians to focus much more of our time on the actual care of the patient. With our present multipayer system, we spend an increasing and inordinate amount of time dealing with pre-authorization of care ordered.
This care includes: Medications, treatments, diagnostic procedures such as CAT scans, MRIs, xrays, and lab work.
Denials by insurance companies are all too frequent. The time spent to gain coverage for the recommended care is increasingly burdensome. A study from the journal, Public Affairs, May 2009, concludes that each physician in America spends $68,000/year just interact with the private health insurance industry.
Our practice participates with 20 different insurance companies, all of which have their own set of rules and hoops to jump through. I have become convinced that their “rules” have much more to do with their profit margin than they do with good patient care.
SB 400 will streamline our care by providing one set of rules by which to practice, based on clinical effectiveness research, clinical outcomes studies that prove the benefit of care we provide, both testing and treatments.
This bill will markedly simplify the current environment in which we work. It truly will give us more time to see patients.
Second, SB 400 will provide improved ability to track and trend physicians’ care with its emphasis on the use of information technology. If there are providers who are not providing the standard of care, these providers will receive constructive criticism with expectation that they will improve their care to their patients.
Third, SB 400 will strengthen the patient/physician relationship. How? Patients will be able to choose their providers of care and stay with them. The present Private Health Insurance dominated system causes patients to leave my practice because their employer can no longer afford the plan they have.
If their plan changes to one that we do not participate in, then the patient is practically forced to leave our practice for a physician’s practice that participates in their plan.
This happens every year in my practice.
SB 400 actually gives the patient the right to choose and stay with their providers. The insurance industry no longer controls this choice with their preferred networks.
I went into Family Practice so that I could take care of patients and their families over the course of many years. I believe that I can provide better care to patients because I know and understand the patient and the people around the patient over time. This has played out in some of my families. Our present lack of a coordinated healthcare system necessitates employers’ frequent decisions to change health insurance plans just so they can afford coverage. This trend has greatly compromised the continuity of care that I believe is so important to quality of care.
Fourth, I believe that SB 400 will provide “fair reimbursement” for providers’ services. Fees for independent providers’ services and global payments for hospitals’ and other institutions’ services will be negotiated annually based on the previous year’s expenditures.
One of the stated goals of SB 400 is to strengthen primary care. This is critical to improved care throughout the state and nation.
We, as a nation, are presently spending at least an extra $400 billion dollars a year in excessive administrative costs due to the Private Health Insurance industry’s role as the middleman.
I believe that if we eliminate the excessive administrative costs of the Private Health Insurance industry, we can save huge sums of money that can be used to provide better care of all Pennsylvanians and can fairly reimburse providers for their care.
Enacted SB 400 will be a win-win for the citizens of Pennsylvania, patients and providers alike.
By the way, don’t forget the 2+ billion dollars per year in savings we will achieve with the reduction in the costs of healthcare premiums of governmental employees when all levels of government in Pennsylvania are considered.
Fifth, I believe that even though the excellent medical liability piece of last year’s bill has been removed, SB 400 will provide an improved medical liability environment in Pennsylvania for all providers.
Presently, part of the award in a medical liability case includes “medical expenses”. SB 400 will pay for medical expenses and therefore this cost will not be added to the award granted to the plaintiff.
This improved medical liability environment will make Pennsylvania a much more attractive state for physicians to practice. I repeat, physicians will want to work in Pennsylvania.
I have followed developments in Washington very carefully this year. At this moment, I believe that their “solution” will fall woefully short of the mark of providing affordable, accessible, high-quality healthcare for all. Our state government has received a few black eyes recently. When your committee leads the way, when our legislators pass SB 400, and when SB 400 is enacted, your will be honored by Pennsylvanians, young and old. Future generations will thank you.
You will be the saviors of our state’s healthcare system.
You will do this while allowing almost all taxpayers to spend much less on healthcare, all costs considered.
Future generations of Americans will credit you as the fathers of our nation’s exemplary, civilized healthcare system, a system in which every person receives healthcare. Pennsylvania will be the state that blazes the trail our nation finally takes to provide civilized healthcare for all.
Thank you!
Sen. Sanders' floor speech on his single payer amendment
United States Senate
December 16, 2009
The reading of the Sanders single payer amendment continues in its third hour…
Senate President: The Senator from Vermont.
Sen. Bernie Sanders: I withdraw my amendment.
Voice off camera (believed to be Sen. Tom Coburn): Regular order, Mr. President.
Senate President: The Senator has that right. The amendment is withdrawn.
Sen. Sanders: Mr. President. Pursuant to the thirty minutes…
Senate President: Under the previous order, the Senator from Vermont is recognized for thirty minutes.
Sen. Sanders: Mr. President, let me begin, not by talking about my amendment, but by talking about Republican action right here on the floor of the Senate. Everybody in this country understands that our nation faces a significant number of major crises, whether it’s the disintegration of our health care system, the fact that seventeen percent of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we’ve got two wars, we’ve got global warming, we have a twelve trillion dollar national debt, and the best the Republicans can do is try to bring the United States government to a halt by forcing a reading of a seven hundred page amendment. That is an outrage! People can have honest disagreements, but in this moment of crisis it is wrong to bring the United States government to a halt.
Now, Mr. President, I am very disturbed that I am unable to bring the amendment that I wanted to bring to the floor of the Senate dealing with a Medicare for all single payer program…
… I was more than aware and very proud that this amendment would have been the first time in American history that a Medicare for all single payer bill was brought before a floor of Congress.
C-SPAN video of Sen. Sanders remarks (36 minutes):
http://www.c-span.org/Watch/watch.aspx?MediaId=HP-A-27367
Yesterday’s Quote of the Day message left off as the reading of the the Sanders amendment to the Senate health reform bill continued. It was suggested that this abuse of process and lack of civility on the part of Sen. Coburn and the Republican leadership be used as a teaching moment. That moment is here. The video of this Senate floor speech by Sen. Sanders should be shared with others who believe that everyone in our nation should have the health care that they need without having to face financial hardship.
Sen. Coburn demands a reading of Sen. Sanders' single payer amendment
United States Senate
December 16, 2009
SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35
Beginning on page 1, strike line 6 and all the follows to the end and insert the following:
(b) Table of Contents.–The table of contents of this Act is as follows:
TITLE I–AMERICAN HEALTH SECURITY
…
Full amendment (366 pages):
http://c-span.org/pdf/sanders_amend_2837.pdf
The reading of the amendment (live now – Dec. 16):
http://www.c-span.org/Watch/C-SPAN2.aspx
Comment:
By Don McCanne, MD
Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.
When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.
After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.
Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.
Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.
At least they can no longer claim that we can’t pass a bill that hasn’t been read.
Sen. Coburn demands a reading of Sen. Sanders’ single payer amendment
United States Senate
December 16, 2009
SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35
Beginning on page 1, strike line 6 and all the follows to the end and insert the following:
(b) Table of Contents.–The table of contents of this Act is as follows:
TITLE I–AMERICAN HEALTH SECURITY
…
Full amendment (366 pages):
http://c-span.org/pdf/sanders_amend_2837.pdf
The reading of the amendment (live now – Dec. 16):
http://www.c-span.org/Watch/C-SPAN2.aspx
Comment:
By Don McCanne, MD
Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.
When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.
After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.
Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.
Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.
At least they can no longer claim that we can’t pass a bill that hasn’t been read.
Sen. Coburn demands a reading of Sen. Sanders' single payer amendment
United States Senate
December 16, 2009
SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35
Beginning on page 1, strike line 6 and all the follows to the end and insert the following:
(b) Table of Contents.–The table of contents of this Act is as follows:
TITLE I–AMERICAN HEALTH SECURITY
…
Full amendment (366 pages):
http://c-span.org/pdf/sanders_amend_2837.pdf
The reading of the amendment (live now – Dec. 16):
http://www.c-span.org/Watch/C-SPAN2.aspx
Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.
When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.
After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.
Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.
Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.
At least they can no longer claim that we can’t pass a bill that hasn’t been read.
Sheils and Haught analyze the House and Senate bills
Comparing the Cost and Coverage Impacts of the House and Senate Leadership Health Reform Bills: Long Term Costs for Governments, Employers, Families and Providers
Prepared for: The Peter G. Peterson Foundation
By John Sheils and Randy Haught
The Lewin Group
December 7, 2009
Impact on National Health Spending
Both bills would result in an increase in administrative costs. These include the cost of administering private insurance to newly covered people, the cost of administering coverage under Medicaid and the cost of processing eligibility for premium subsidies under the bill.
Both bills would result in a substantial growth in national health expenditures. Total health spending over the 2010 through 2029 period would increase by $781 billion under the Senate bill and $955 billion under the House bill.
http://www.pgpf.org/resources/lewin-senate-house-comparison.pdf
Comment:
By Don McCanne, MD
What is health care reform going to cost us? To help answer this question, numerous reports have been generated by the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), the Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS), the Council of Economic Advisers (CEA), private foundations, and numerous consulting firms representing the private insurance industry.
Although politicians are using sections of these reports selectively to advance their own agendas, if you read all of the reports you cannot escape the conclusion that the measures designed to slow the growth in health care costs do not begin to offset the anticipated increases in spending. Further, they show that an unacceptable number of individuals will remain amongst the ranks of the uninsured.
This new, highly credible report (credible in spite of ownership by UnitedHealth) by John Sheils and Randy Haught draws the same conclusions. National health expenditures will increase over the amounts projected were there no reform, and about 20 million people will still be uninsured.
One comparatively small number in this report is that administrative costs will increase by about $87 billion in the next decade under either the Senate or the House bill. But this number has much greater significance than the amount would suggest. Not only is this an additional cost, it also adds on to the $4,000 billion in administrative waste that we could recover in the next decade if we merely changed to a single payer system of financing health care. That would free up enough funds to cover our nation’s unmet health care needs.
Sheils and Haught analyze the House and Senate bills
Comparing the Cost and Coverage Impacts of the House and Senate Leadership Health Reform Bills: Long Term Costs for Governments, Employers, Families and Providers
Prepared for: The Peter G. Peterson Foundation
By John Sheils and Randy Haught
The Lewin Group
December 7, 2009
Impact on National Health Spending
Both bills would result in an increase in administrative costs. These include the cost of administering private insurance to newly covered people, the cost of administering coverage under Medicaid and the cost of processing eligibility for premium subsidies under the bill.
Both bills would result in a substantial growth in national health expenditures. Total health spending over the 2010 through 2029 period would increase by $781 billion under the Senate bill and $955 billion under the House bill.
http://www.pgpf.org/resources/lewin-senate-house-comparison.pdf
What is health care reform going to cost us? To help answer this question, numerous reports have been generated by the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), the Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS), the Council of Economic Advisers (CEA), private foundations, and numerous consulting firms representing the private insurance industry.
Although politicians are using sections of these reports selectively to advance their own agendas, if you read all of the reports you cannot escape the conclusion that the measures designed to slow the growth in health care costs do not begin to offset the anticipated increases in spending. Further, they show that an unacceptable number of individuals will remain amongst the ranks of the uninsured.
This new, highly credible report (credible in spite of ownership by UnitedHealth) by John Sheils and Randy Haught draws the same conclusions. National health expenditures will increase over the amounts projected were there no reform, and about 20 million people will still be uninsured.
One comparatively small number in this report is that administrative costs will increase by about $87 billion in the next decade under either the Senate or the House bill. But this number has much greater significance than the amount would suggest. Not only is this an additional cost, it also adds on to the $4,000 billion in administrative waste that we could recover in the next decade if we merely changed to a single payer system of financing health care. That would free up enough funds to cover our nation’s unmet health care needs.
Gawande’s Rx is no solution
[The following letter to Washington Post columnist David Broder from Dr. Ray Bellamy of Florida discusses not only Broder’s recent arguments, but also those of Dr. Atul Gawande at The New Yorker.]
December 11, 2009
Mr. David Broder
Washington Post Writers Group
1150 15th Street NW
Washington, DC 20071
Dear Mr. Broder,
I read with interest your column titled “Health Care Brings Freshman Senators to the Forefront” in today’s edition of the Tallahassee Democrat. I agree cost control is the key issue in health reform and has not been addressed in current congressional efforts. The output from Congress seems focused mostly on what is politically possible and increasingly on what can be supported by 60 votes, not true reform.
The mainstream media seems to have bought into the notion that, since the Republicans are trying to block reform and perhaps make health reform “Obama’s Waterloo,” the House and Senate output should be supported. Although allowing for deep flaws in the legislation, there is the feeling that incremental steps toward a better system are good. You and the excellent writer you reference, Dr. Atul Gawande, have apparently bought into this mindset. Allow me to disagree.
Gawande, in his latest article in The New Yorker titled “Testing, testing,” speaks of small-scale pilot projects in the proposed legislation with hope they will show the way toward cost savings.
Yet we already have pilot projects all over the world that have met with dramatic success: nearly every other developed country has universal coverage with higher citizen satisfaction and far higher medical outcomes at roughly half the per-capita cost as U.S. health care. Half the cost.
Why do we need new pilot projects? We have the knowledge that the only two successful health care models in these countries are either (1) highly regulated nonprofit insurers who sell health policies as an inducement to the purchase of profitable property, fire and auto insurance, or (2) some version of single payer.
We know no country utilizes a system like the model Congress is proposing and that none like it has ever been successful. Eight prior state efforts using this model all failed, usually within a few years. Massachusetts, currently starting its third year with a similar model, is not able to control costs, and has the most expensive health insurance in the world. This is the model for what Congress has proposed.
Medicare for All is criticized for being a “government takeover.” Really, we have entrusted health care to private insurance long enough to know that their business model of avoiding the sick, then dumping those who do need care rather than spreading the risk as insurance is supposed to do, does not work. Medicare has a 92 percent enrollee satisfaction rate. Private insurance cannot approach that.
Critics also charge that Medicare is bankrupt. What do you expect when the funding is provided by a dwindling collection of payroll taxes from fewer and fewer workers to support current Medicare enrollees who are swelling in numbers? Funding Medicare with a 2 percent or 3 percent progressive income tax would be the answer – an amount that would certainly be less than what most people pay today for premiums, co-pays, deductibles, uncovered services and other out-of-pocket health care costs.
The individual mandate to have insurance, as proposed by the House, is an effort to avoid adverse risk selection, which occurs when those who are currently young and healthy wait to purchase insurance until they get sick. Insurance obviously works best with the largest possible risk pool and that is why health savings accounts and skimpy coverage for different groups are bad ideas. What would work best is every American covered in the same risk pool. We could have comprehensive coverage, all with the same policy as every member of Congress – truly egalitarian – for what we currently pay in health care in this country now: $2.4 trillion annually.
Gawande mentions the benefits of improved information about what works, comparative effectiveness, and the problem of overutilization (which he headlined in his previous New Yorker article). Yet look what instant information would be available if we had single payer: instant data on comparative effectiveness, overutilization, and disease outbreaks anywhere in the country.
Gawande has also written about a Texas border town, McAllen, with high utilization and cost. His information was obtained through Medicare data, which is the best nationwide health care data we have available. Single payer would give us such high-quality information instantly for the entire nation, not just the Medicare population.
Gawande also speaks of the need for tort reform, of which there is essentially none in current congressional proposals. If we had truly universal comprehensive, egalitarian Medicare for All, we would eliminate the cost of future medical expenses from all personal injury lawsuits, not just Med-Mal. This is a major component of economic damages in personal injury lawsuits.
Current congressional proposals retain the main low-hanging fruit for cost cutting and reward it: the wasteful administrative expense, marketing cost, profits of the for-profit insurance industry. To the current 31 percent administrative waste in the system, Congress proposes to add additional bureaucracy and a czar so we are likely to reach 35 percent overhead and waste. That figure, the highest in the world almost by a factor of two, could be lowered for a saving of $400 billion a year within our current budget, with the savings used to cover every one of us without raising costs.
The additional opportunity to sensibly manage our nation’s health budget with the inevitable rationing decisions necessary in the future, with global budgeting and so on, would also stem from a single-payer system.
Now one last word on true reform: if we moved away from fee-for-service reimbursement for physicians and instead provided incentives for them take salaried positions, like those in the Veterans Administration and the U.S. military (along with those at the Mayo Clinic), there would likely be huge additional savings. Socialized medicine? No. By and large, you’d still private physicians working in private hospitals.
Under a single-payer arrangement, patients would have more free choice of physician and hospital than we have now. Every American would have the choice to go to the Mayo Clinic, so the competition would surely result in improvements for all facilities and caregivers.
I read what you write and what Dr. Gawande writes with interest, but in this case I strongly disagree. Congress needs to start over on health reform, and this time it needs to compare single-payer Medicare for All with other options. I guarantee you that single payer will win hands down.
Sincerely,
Ray Bellamy, M.D.
Dr. Ray Bellamy is an orthopedic surgeon in Tallahassee, Fla.
Evidence Based Talking Points
Talking Point 1: Administrative costs consume 31 percent of health spending, most of it unnecessary.
“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.
Talking Point 2: Nearly two-thirds of all bankruptcies are caused by medical bills. Three-fourths of those bankrupted had health insurance at the time they got sick or injured.
“Medical Bankruptcy in the United States, 2007: Results of a National Study.” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009), Am J Med, 122, 741-746.
“Medical Bankruptcy Fact Sheet.” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009).
“Medical Bankruptcy Q&A.” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009).
Talking Point 3: Taxes already pay for more than 60 percent of US health spending Americans pay the highest health care taxes in the world. We pay for national health insurance, but don’t get it.
“Paying for National Health Insurance – And Not Getting It.” Woolhandler, S. & Himmelstein, D.U. (2002), Health Affairs 21(4), 88-98.
Talking Point 4: Despite spending far less per capita for health care, Canadians are healthier and have better measures of access to health care than Americans. Taiwan’s new single payer system (adopted in 1996) has improved access to care (before its adoption, 40 percent of the population was uninsured), controlled costs, and is model of efficiency. Despite having the highest per capita health spending in the world, the U.S. health system ranks very poorly in international comparisons of quality, outcomes, patient satisfaction, and other measures.
“Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey.” Lasser, K., Himmelstein, D.U., & Woolhandler, S. (2006), Am J Public Health, 96, 1300-1307.
“Does Universal Health Insurance Make Health Care Unaffordable? Lessons from Taiwan.” Lu, J.F.R. & Hsiao, W.C. (2003), Health Affairs, 22(3), 77-88.
“Learning from Taiwan: Experience with Universal Health Insurance.” Davis, K. & Huang, A.T. (2008), Ann Intern Med, 148, 313-314.
“It’s The Prices, Stupid: Why The United States is So Different From Other Countries.” Anderson, G., Reinhardt, U.E., Hussey, P.S., & Petrosyan, V. (2003), Health Affairs, 22(3), 89-105.
Talking Point 5: Business pays less than 20 percent of our nation’s health bill. It is a misnomer that our health system is “privately financed.” 60 percent is funded by taxes and the remaining 20 percent is out-of-pocket payments.
“A Reappraisal of Private Employers’ Role in Providing Health Insurance.” Carrasquillo, O., Himmelstein, D.U., Woolhandler, S., & Bor, D.H. (1999), N Engl J Med, 340, 109-114.
Talking Point 6: For-profit, investor-owned hospitals, HMOs, and nursing homes have higher costs and score lower on most measures of quality than their non-profit counterparts. For-profit hospitals have higher death rates.
“The high costs of for-profit care.” Himmelstein, D. & Woolhandler, S. (2004), Can Med Assoc J, 170, 1814-1815.
“Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis.” Devereaux, P.J., et. al. (2004), Can Med Assoc J, 170, 1817-1824.
“A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals.” Devereaux, P.J., et. al. (2002), Can Med Assoc J, 166, 1399-1406.
“Costs of Care and Administration at For-Profit and Other Hospitals in the United States.” Woolhandler, S., & Himmelstein, D.U. (1997), N Engl J Med, 336, 769-775.
“Quality of Care in Investor-Owned vs. Not-for-Profit HMOs.” Himmelstein, D.U., Woolhandler, S., Hellander, I., & Wolfe, S.M. (1999), J Am Med Assoc, 282, 159-163.
“Does Investor Ownership of Nursing Homes Compromise the Quality of Care?” Harrington, C., Woolhandler, S., Mullan, J., Carrillo, H., & Himmelstein, D.U. (2001), Am J Public Health, 91, 1452-1455.
“Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis.” Vikram R Comondore, P J Devereaux et al, BMJ 2009;339:b2732, doi: 10.1136/bmj.b2732, Aug. 4, 2009.
Talking Point 7: Immigrants and emergency department visits by the uninsured are not the cause of high and rising health care costs.
“Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” Mohanty, S., et. al. (2005), Am J Public Health, 95, 1431-1438.
“US Emergency Department Costs: No Emergency.” Tyrance, P.H., Himmelstein, D.U., & Woolhandler, S. (1996), Am J Public Health, 95, 1527-1531.
Talking Point 8: The uninsured do not receive all the medical care they need: one-third of uninsured adults have chronic illness and don’t receive needed care. Those most in need of preventive services are least likely to receive them.
“A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults.” Wilper, A., et. al. (2008), Arch Intern Med, 149, 170 – 176.
Talking Point 9: The U.S. could save enough on administrative costs (almost $400 billion in 2009) with a single-payer system to cover the uninsured.
“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.
“Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance.” Woolhandler, S., Himmelstein, D.U., Angell, M., & Young, Q.D. (2003), J Am Med Assoc 290, 798-805.
“Summary of Fiscal Studies: How Much would Single Payer Cost?”
“Canadian Health Insurance: Lessons for the Unites States.” U.S. General Accounting Office. (1991), GAO/HRD-91-90 Canadian Health Insurance.
Talking Point 10: Competition among investor-owned, for-profit entities has raised costs reduced quality in the U.S.
“Competition in a publicly funded healthcare system.” Woolhandler, S. & Himmelstein, D.U. (2007), Brit Med J, 335, 1126-1129.
“Market-Based Failure – A Second Opinion on U.S. Health Care Costs.” Kuttner, R. (2008), N Engl J Med, 358, 549-551.
Talking Point 11: The Canadian single payer healthcare system produces better health outcomes with substantially lower administrative costs than the United States.
“A systematic review of studies comparing health outcomes in Canada and the United States.” Guyatt G.H., et al. (2007), Open Medicine, 1, E27-36.
“Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey.” Lasser, K., Himmelstein, D.U., & Woolhandler, S. (2006), Am J Public Health, 96, 1300-1307.
“Who administers? Who cares? Medical Administrative and Clinical Employment in the United States and Canada.” Himmelstein, D., Lewontin, J.P., & Woolhandler, S. (1996), Am J Public Health, 86,172-178.
“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.
“Mythbusters: Canada has a communist-style healthcare system.” Canadian Health Services Research Foundation. (2005).
“Mythbusters: The cost of dying is an increasing strain on the healthcare system.” Canadian Health Services Research Foundation. (2003).
“Mythbusters: User fees would stop waste and ensure better use of the healthcare system.” Canadian Health Services Research Foundation. (2001).
“Privatizing health care is not the answer: lessons from the United States.” Angell, M. (2008), Can Med Assoc J, 179, 916-919.
Talking Point 12: Computerized medical records, chronic disease management, and malpractice reform do not save money. The only way to slash administrative over-head and improve quality is with a single payer system.
“Hospital computing and the costs and quality of care: a national study.” Himmelstein, D.U., Wright, A & Woolhandler, S. (2009), Am J Med, 2009 Nov 16.
“Hope And Hype: Predicting The Impact Of Electronic Medical Records.” Himmelstein, D.U. & Woolhandler, S. (2005), Health Affairs, 24, 1121-1123.
“Disease Management: Panacea, Another False Hope, or Something in Between?” Geyman, J. (2007), Ann Fam Med, 5, 257-260.
“Costs of Health Care Administration in the U.S. and Canada.” Woolhandler, S., Campbell, T., & Himmelstein, D.U. (2003), N Engl J Med, 349, 768-775.
“A Better Quality Alternative: Single-Payer National Health System Reform.” Schiff, G.D., Bindman, A.B., & Brennan, T.A. (1994), J Am Med Assoc, 272, 803-808.
“How Single-Payer Health System Reform Improves Quality.” PNHP Document
“You Can’t Leap a Chasm in Two Jumps: The Institute of Medicine Health Care Quality Report.” Schiff, G.D. & Young, Q.D. (2001), Public Health Rep, 116, 396-403.
“Medical Malpractice. Health Care Quality and Health Care Reform.” Schiff, G. (2003), Forum Report #4. PNHP NY Metro.
Talking Point 13: Alternative proposals for “universal coverage” (e.g. based on the Federal Employees Health Benefits Program, the old “Clinton health plan” or the recent reform in Massachusetts) do not work. State health reforms over the past two decades have failed to reduce the number of uninsured.
“State Health Reform Flatlines.” Woolhandler, S., Day, B., & Himmelstein, D.U. (2008), Int J Health Serv, 38, 585-592.
“FEHBP: A Feeble Model for Universal Health Care.” Rodberg, L. & Landy, J. (2004), On the Issues #2. PNHP NY Metro.
“Health Reform You Shouldn’t Believe In.” Angell, M. (2008), The American Prospect, April 21.
“Getting the Facts Right: Why HillaryCare Failed.” Navarro, V. (2007), PNHP Newsletter.
“The Massachusetts Way?” Rodberg, L. (2008), The New York Times, Sept. 26.
Talking Point 14: Drug companies spend more on marketing (31 percent) and profits (20 percent) than on R & D (13 percent). Lower drug prices would not jeopardize drug innovation, much of which is, in fact, publicly-funded.
“Extraordinary Claims Require Extraordinary Evidence.” Light, D.W. & Warburton, R.N. (2005), J Health Econ, 24, 1030-1033.
“Global Drug Discovery: Europe Is Ahead.” Light, D.W. (2009), Health Affairs, web exclusive, w969-w977.
“Will Lower Drug Prices Jeopardize Drug Research? A Policy Fact Sheet.” Light, D.W. & Lexchin, J. (2004), Am J Bioethics, 4, W3-W6.
“Foreign Free Riders and the High Price of U.S. Medicines.” Light, D.W. & Lexchin, J. (2005), Brit Med J, 331, 958-60.
Talking Point 15: Co-pays and deductibles are not necessary to control costs and reduce necessary care as much as unnecessary care. It is a myth that patient overuse will bankrupt any system without cost-sharing and that the demand for healthcare is “infinite”.
“Cost Sharing in Health Insurance – A Reexamination.” Rasell, M.E. (1995), N Engl J Med, 332, 1164-1168.
“Health needs, health-care requirements, and the myth of infinite demand.” Frankel, S. (1991), Lancet, 337, 1588-1590.
“Does universal comprehensive insurance encourage unnecessary use? Evidence from Manitoba says ‘no.’” Roos, N.P., Forget, E., Walld, R., & MacWilliam, L. (2004), Can Med Assoc J, 170, 209-214.
Talking Point 16: Universal coverage cannot be achieved with U.S.-style investor-owned private insurance companies. Every other industrialized, capitalist country has some form of non-profit national health care. For-profit, private insurance (mostly “gap” coverage) accounts for less than 5 percent of health expenditures in Europe.
“International Health Systems for Single Payer Advocates.” Hellander, I.
“PBS Frontline Interview with T.R. Reid, Fall 2008.” Reid, T.R. (2008).
“Sick Around the World.” Reid, T.R. (2008).
“Private health insurance and access to health care in the European Union.” Thompson, S. & Mossialos, E. (2004), Euro Observer, 6(1).
“Health Care Systems – Four Basic Models.” Reid, T.R.
“Health care reform must start with a plan to simplify.” McCanne, D. (2008), Quote of the Day, Sept. 18.
Talking Point 17: A majority of physicians (59 percent), and an even higher proportion of Americans (two-thirds) support single payer national health insurance or “Medicare for all.” Polling indicates that people are also willing to pay “higher taxes” for guaranteed coverage and that even the term “socialized medicine” has lost its negative connotations.
“Support for National Health Insurance among U.S. Physicians: 5 Years Later.” Carroll, A.E. & Ackerman, R.T. (2008), Ann Intern Med, 148, 566.
“Single-Payer, Health Savings Accounts, or Managed Care? Minnesota Physicians Perspective.” Albers, J.M., Lathrop, B.P., Allison, K.C., Oberg, C.N., & Hart, J.F. (2007), Minn Med, 90, February.
“PNHP Backgrounder: Recent Public Polls on Single Payer.” PNHP. (2007).
“PNHP Backgrounder: Physician Polls on Single Payer Prior to 2008.” PNHP. (2008).
'Medicare buy-in' called a subsidy to private insurers
The following radio interview with Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program and professor at Harvard Medical School, took place on the morning of Dec. 9 with an affiliate of Los Angeles-based KPFK Pacifica. A number of details about the bill were still unknown at that time.
Click here to listen to the interview.
Is it accurate to say that, even though this version of the Senate bill is still using the term “public option,” it’s really now going to be run by private health insurance companies?
That’s true. What the “public option” is going to be for folks under the age of 55 is just a menu, a menu of private plans that they can buy. It’s similar to the menu that is offered to federal workers, but of course federal workers actually get money to buy the health insurance. They don’t just get the menu, they get the money. So under the age of 55, if you’re uninsured, you will be offered this menu of nonprofit plans.
The issue about the folks over the age of 55 being able to buy into Medicare is actually quite bad as well. One of the better provisions of the reform legislation was that it prohibited charging older people any more than twice (or thrice in the some versions) as much as you charge younger people in the individual market. But by saying anyone over 55 in the individual market can be picked up by Medicare, you’ve really let the insurance industry off the hook.
That is, the highest-cost patients in the individual market will be taken off the insurance companies’ hands and paid for by the taxpayers; and private insurance will remain the only option for people under the age of 55 and for anyone who gets their insurance through their employer. Another way of saying that is: if you now have private health insurance and you don’t like it, you’re forced to keep it.
The buy-in to Medicare is only for those 55 to 64 and it’s only for people who are not offered private health insurance through an employer. So it turns into just a subsidy to private health insurance: the taxpayers will pay for the high-cost patients and the health insurance industry can take the lower-cost patients.
I want to remind people that at its core, this bill takes $450 billion in new taxes from the taxpayers, and hands it over to the private health insurance as subsidies. So, the core of the bill is a financial strengthening of the private health insurance industry. And even one of the small things that was good about the plan, that is, forcing the insurance industry to lower the prices for older enrollees – that’s been taken out of the bill, essentially.
Explain the subsidy, a little bit further; is this what the government would offer, as help for low-income Americans who cannot buy insurance? Because this bill, I’m assuming, also still has the mandate that all Americans have insurance, is that true?
That’s true. I live in Massachusetts, where we already have a very similar plan in place, and people do get subsidies if their income is less than 300 percent of poverty. The problem is that the subsidies are not very large, so you might get several thousand dollars in subsidy, but your insurance plan might be $10,000 or even $15,000, so that the mandate forces many low-income people to continue to take thousands of dollars out of their pocket and hand it to the private health insurance industry. So, in effect, the taxpayers are giving money to private health insurance, the individual family is being forced to hand over thousands more to the private health insurance industry.
What do you make of the words of Senator Max Baucus, who’s been a leading figure in the health care reform movement coming from the state of Montana, and getting huge numbers of campaign contributions from insurance companies? He is claiming that this compromised bill is the only kind of proposal, he said it’s probably the closest proposal so far that could get the support of 60 senators. “It’s got legs,” he says.
The issue here is what private health insurance wants. They did give Max Baucus $1.4 million in campaign contributions, but more significantly than that, Max Baucus has an assistant who’s actually writing the bill. We know she’s writing the bill because when you look at the documents that the Senate Finance Committee is putting out, for instance the so-called Baucus Framework, and you right-click and look at the properties box, you’ll see that the framework was written on the computer of Elizabeth Fowler. Her previous job was as vice president of WellPoint, the nation’s largest insurance company. So the insurance company is right there, on the inside, writing this bill. Not a word goes on that piece of paper that they don’t have an influence on. And when you look at something like the Medicare buy-in, you have to ask, “Well, what did the insurance industry get out of it?” because they have indeed hijacked this process and are writing the bills. Now they’re lobbying with these swing senators to get more and more and more of what the private insurance industry wants out of the bill.
One of the things in the House version of the bill that did, have some, that some progressives did like was the possibility that states individually could potentially start their own single-payer system. What’s the status of that in this bill?
An amendment was put forth in the House but not included in the final bill would have allowed state single-payer bills. Senator Bernie Sanders has been talking about putting an amendment forward in the Senate. We certainly expect to see that and hope that he’ll do that. But the bill that seems likely to emerge from the Senate and from the conference committee will probably not have that single-payer option in it. We’d like to see it because that would encourage people at the state level to continue to work on single payer, it would make their work easier, but we doubt that is actually going to be in the final bill. We’re still hopeful, but we doubt it.
I think we have to look at the totality of the bill at this point, and the totality of the bill is that it’s absolutely no solution. It’s going to make some people better off, some people worse off, but it’s going to leave us with probably 25 million uninsured people when fully implemented in 2020. It’s going to cost the taxpayers $450 billion in taxes that end up going straight to the private insurance industry as subsidies. There are many, many bad things in this bill that reflect the role of the insurance industry.
There is also the amendment that would prohibit any kind of government subsidies for plans that might offer abortion services; again, this is similar to the House version of the bill that was put forward as a way to get the votes of pro-life, anti-abortion senators.
Well, the anti-abortion planks are still in play. That is, within the House version there is a complete prohibition on plans sold through the exchange covering abortion. That’s obviously a major step backwards for reproductive rights. Right now, government money can’t support abortions, but there’s never before been a restriction on private plans. So, the House bill for the first time would put a restriction on abortion into private health insurance plans.
In the Senate, my understanding is that it is still in play. Senator Nelson is saying he refuses to support the bill unless he gets a Stupak [anti-abortion] amendment in there. The proposal on the table is to come up with some elaborate system to try and separate the monies that are public and private so that private plans might still offer abortions, but only out of the private monies, but that issue is still in play in the Senate bill.
It’s amazing that they are still calling the health insurance exchange, th
e private health insurance exchange, a public option. Do you see this step in the entire health care debate as basically being just not really worth carrying on anymore, from your perspective? You’d like to just stop and start over?
Yes. I think we need to start from scratch and throw this bill away. We need to start over, with the Medicare-for-All framework: that everyone in the country would have the same type of insurance that would be paid for by taxes, that the patients would have complete free choice of doctor or hospital.
The beauty of the Medicare-for-All approach is that you get so much on administrative savings that you can pay for the expanded access. You save more than $350 billion annually through administrative simplification and that’s the money you need not only to cover all of the uninsured, but also to plug the gaps in coverage for people who now have private coverage with gaps in it.
That’s the direction we need to be heading – toward that single payer. As long as we are leaving the private health insurance industry in the bill, it’s enormously expensive. One of the aspects of the bill that we haven’t discussed is that it has 10 years of taxes in it, but only 6 years of new coverage. That is, the tax provisions go into effect immediately, but all of the coverage provisions go into effect in 2014. So the only way they even got this bill to balance financially is by putting 10 years of taxes against 6 years of coverage. So the bill is really not affordable. Even if your only issue or concern was about cost and affordability, this bill is not affordable over the long run.
‘Medicare buy-in’ called a subsidy to private insurers
The following radio interview with Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program and professor at Harvard Medical School, took place on the morning of Dec. 9 with an affiliate of Los Angeles-based KPFK Pacifica. A number of details about the bill were still unknown at that time.
Click here to listen to the interview.
Is it accurate to say that, even though this version of the Senate bill is still using the term “public option,” it’s really now going to be run by private health insurance companies?
That’s true. What the “public option” is going to be for folks under the age of 55 is just a menu, a menu of private plans that they can buy. It’s similar to the menu that is offered to federal workers, but of course federal workers actually get money to buy the health insurance. They don’t just get the menu, they get the money. So under the age of 55, if you’re uninsured, you will be offered this menu of nonprofit plans.
The issue about the folks over the age of 55 being able to buy into Medicare is actually quite bad as well. One of the better provisions of the reform legislation was that it prohibited charging older people any more than twice (or thrice in the some versions) as much as you charge younger people in the individual market. But by saying anyone over 55 in the individual market can be picked up by Medicare, you’ve really let the insurance industry off the hook.
That is, the highest-cost patients in the individual market will be taken off the insurance companies’ hands and paid for by the taxpayers; and private insurance will remain the only option for people under the age of 55 and for anyone who gets their insurance through their employer. Another way of saying that is: if you now have private health insurance and you don’t like it, you’re forced to keep it.
The buy-in to Medicare is only for those 55 to 64 and it’s only for people who are not offered private health insurance through an employer. So it turns into just a subsidy to private health insurance: the taxpayers will pay for the high-cost patients and the health insurance industry can take the lower-cost patients.
I want to remind people that at its core, this bill takes $450 billion in new taxes from the taxpayers, and hands it over to the private health insurance as subsidies. So, the core of the bill is a financial strengthening of the private health insurance industry. And even one of the small things that was good about the plan, that is, forcing the insurance industry to lower the prices for older enrollees – that’s been taken out of the bill, essentially.
Explain the subsidy, a little bit further; is this what the government would offer, as help for low-income Americans who cannot buy insurance? Because this bill, I’m assuming, also still has the mandate that all Americans have insurance, is that true?
That’s true. I live in Massachusetts, where we already have a very similar plan in place, and people do get subsidies if their income is less than 300 percent of poverty. The problem is that the subsidies are not very large, so you might get several thousand dollars in subsidy, but your insurance plan might be $10,000 or even $15,000, so that the mandate forces many low-income people to continue to take thousands of dollars out of their pocket and hand it to the private health insurance industry. So, in effect, the taxpayers are giving money to private health insurance, the individual family is being forced to hand over thousands more to the private health insurance industry.
What do you make of the words of Senator Max Baucus, who’s been a leading figure in the health care reform movement coming from the state of Montana, and getting huge numbers of campaign contributions from insurance companies? He is claiming that this compromised bill is the only kind of proposal, he said it’s probably the closest proposal so far that could get the support of 60 senators. “It’s got legs,” he says.
The issue here is what private health insurance wants. They did give Max Baucus $1.4 million in campaign contributions, but more significantly than that, Max Baucus has an assistant who’s actually writing the bill. We know she’s writing the bill because when you look at the documents that the Senate Finance Committee is putting out, for instance the so-called Baucus Framework, and you right-click and look at the properties box, you’ll see that the framework was written on the computer of Elizabeth Fowler. Her previous job was as vice president of WellPoint, the nation’s largest insurance company. So the insurance company is right there, on the inside, writing this bill. Not a word goes on that piece of paper that they don’t have an influence on. And when you look at something like the Medicare buy-in, you have to ask, “Well, what did the insurance industry get out of it?” because they have indeed hijacked this process and are writing the bills. Now they’re lobbying with these swing senators to get more and more and more of what the private insurance industry wants out of the bill.
One of the things in the House version of the bill that did, have some, that some progressives did like was the possibility that states individually could potentially start their own single-payer system. What’s the status of that in this bill?
An amendment was put forth in the House but not included in the final bill would have allowed state single-payer bills. Senator Bernie Sanders has been talking about putting an amendment forward in the Senate. We certainly expect to see that and hope that he’ll do that. But the bill that seems likely to emerge from the Senate and from the conference committee will probably not have that single-payer option in it. We’d like to see it because that would encourage people at the state level to continue to work on single payer, it would make their work easier, but we doubt that is actually going to be in the final bill. We’re still hopeful, but we doubt it.
I think we have to look at the totality of the bill at this point, and the totality of the bill is that it’s absolutely no solution. It’s going to make some people better off, some people worse off, but it’s going to leave us with probably 25 million uninsured people when fully implemented in 2020. It’s going to cost the taxpayers $450 billion in taxes that end up going straight to the private insurance industry as subsidies. There are many, many bad things in this bill that reflect the role of the insurance industry.
There is also the amendment that would prohibit any kind of government subsidies for plans that might offer abortion services; again, this is similar to the House version of the bill that was put forward as a way to get the votes of pro-life, anti-abortion senators.
Well, the anti-abortion planks are still in play. That is, within the House version there is a complete prohibition on plans sold through the exchange covering abortion. That’s obviously a major step backwards for reproductive rights. Right now, government money can’t support abortions, but there’s never before been a restriction on private plans. So, the House bill for the first time would put a restriction on abortion into private health insurance plans.
In the Senate, my understanding is that it is still in play. Senator Nelson is saying he refuses to support the bill unless he gets a Stupak [anti-abortion] amendment in there. The proposal on the table is to come up with some elaborate system to try and separate the monies that are public and private so that private plans might still offer abortions, but only out of the private monies, but that issue is still in play in the Senate bill.
It’s amazing that they are still calling the health insurance exchange, the private health insurance exchange, a public option. Do you see this step in the entire health care debate as basically being just not really worth carrying on anymore, from your perspective? You’d like to just stop and start over?
Yes. I think we need to start from scratch and throw this bill away. We need to start over, with the Medicare-for-All framework: that everyone in the country would have the same type of insurance that would be paid for by taxes, that the patients would have complete free choice of doctor or hospital.
The beauty of the Medicare-for-All approach is that you get so much on administrative savings that you can pay for the expanded access. You save more than $350 billion annually through administrative simplification and that’s the money you need not only to cover all of the uninsured, but also to plug the gaps in coverage for people who now have private coverage with gaps in it.
That’s the direction we need to be heading – toward that single payer. As long as we are leaving the private health insurance industry in the bill, it’s enormously expensive. One of the aspects of the bill that we haven’t discussed is that it has 10 years of taxes in it, but only 6 years of new coverage. That is, the tax provisions go into effect immediately, but all of the coverage provisions go into effect in 2014. So the only way they even got this bill to balance financially is by putting 10 years of taxes against 6 years of coverage. So the bill is really not affordable. Even if your only issue or concern was about cost and affordability, this bill is not affordable over the long run.