PNHP

Medicare buy-in?

Medicare buy-in?

Harry Reid: Democrats reach 'broad agreement'

By Carrie Budoff Brown & Patrick O’Connor
Politico
December 9, 2009

Senate Democrats have reached a “broad agreement” on a health reform bill, Majority Leader Harry Reid said Tuesday night — a plan that would replace the public option in the current Senate bill with a new national insurance plan offered by private insurers, and a chance for older Americans to “buy in” to Medicare.

To win over liberals disappointed at losing the public option, Democrats would allow older Americans starting at age 55 to buy into Medicare, the popular program for the aged. The Medicare expansion would be a significant victory for Democrats, who spent years pushing for it. The proposal would in effect create a public health insurance option for older Americans, since Medicare is government-funded and government-run.

http://www.politico.com/news/stories/1209/30371.html

Comment:

By Don McCanne, MD

The most efficient, most effective, and least expensive method of providing reasonably comprehensive health care for everyone would be to replace all current public and private financing programs with a single, improved Medicare program that covered absolutely everyone. Some have suggested that we can do this incrementally, with the first step being to allow individuals 55 and over to buy into Medicare. Is this a good idea?

Harvard professor Steffie Woolhandler provides us with some insight: “Lowering the eligibility age for Medicare to 55 only works if it is mandatory.  Otherwise it becomes the place where all the sickest patients get dumped.  That might be okay for the sick people since Medicare is often better and more secure than private coverage, but it would drive total health care costs (and premiums) up, not down.”

The current Medicare risk pool is composed of seniors with a high rate of chronic disease and with the expenses of end-of-life care, plus younger individuals with long-term disabilities. Since this is a very high cost population, the prorated premiums would be unaffordable for most individuals 55 thru 64. A separate risk pool would have to be established that would be limited to this age bracket. Unfortunately, 55 thru 64 is still the most expensive age sector of all individuals under 65 and so premiums would still be unaffordable for most, especially after you add in the impact of adverse selection as Steffie Woolhandler has described.

Suppose that a Medicare buy-in for those over 55 were to be established, and that higher government subsidies were provided to cover the higher costs, then what do you have? You have created a public option. Yet the reason being given for the Medicare buy-in is that it is a trade-off to get the progressives to agree to abandoning the public option.

So the agreement seems to be to eliminate the public option from consideration by establishing a public option. But is the proposal a public option that would allow everyone the opportunity to buy into Medicare? Apparently not. After all, this is Congress at work.

Although details have not been released, it appears that this Medicare buy-in would be limited by the same rules already proposed for the public option. Individuals who already are eligible for employer-sponsored coverage, Medicare, or Medicaid would not be eligible to participate in the insurance exchange, yet the Medicare buy-in would not be available outside of the exchange (except perhaps during a transition before the exchange is established). Thus the net effect of this buy-in is to further limit the public option only to those 55 and over who meet all other qualifications for the exchange – a ratcheted-down version of the public option.

An elective buy-in for Medicare will only add to the perpetuation of inequities, fragmentation, administrative inefficiencies, inadequate fiscal supervision and other deficiencies that plague our health care financing system. Adding to our dysfunctional system only compounds the dysfunction. We need to replace the system with an efficient single payer model.

Could we do that in incremental steps by first moving absolutely everyone over 55 into our existing Medicare program? Yes, but why would we do that? There would be complex transitional issues in changing this sector from a revenue source for Medicare into both a revenue source and an expense as they become beneficiaries of the program. Another increment could be MediKids for all children, though that would involve other transitional issues. Then how soon would we phase in everyone else, with yet still more transitional issues?

Incremental steps increase the complexities and costs of the transition while delaying access for many who already have impaired access and financial burdens caused  by our dysfunctional system.

A single, disruptive transition would actually be more efficient administratively, while lowering transitional costs. Much more important, a single transition would ensure that no person would have to wait any longer to access the care that he or she needs merely because of an inability to pay for that care.

If we advocate for less than we need, we’ll end up with cheap chits that will eventually be traded away, and then what are we left with?

INTERVIEW: Dr. Andy Coates

Selling out health care reform

By Ashley Smith
December 9, 2009

The battle for health care reform is heating up in Congress. The House has already passed one bill, and the Senate is debating another version. But as Dr. Andy Coates explains, both bills will fail in solving the health care crisis–and, in fact, place a greater financial burden than ever on working people.

Coates is a member of Physicians for a National Health Program (PNHP), co-chair of Single Payer New York and a steward in the Public Employees Federation in New York. He talked to Ashley Smith about what’s wrong with the health care proposals in Washington.

We’ve heard lots of hype from the Democrats about the House and Senate bills. What’s in these two bills, and what will they mean for workers?

The crux of each bill is compulsory private health insurance. The government will use its power to compel every individual to purchase private health insurance, or enroll in Medicaid. The bills don’t make private health insurance affordable; they propose to subsidize private insurance premiums for those who live on modest means.

For example, the House bill will subsidize the premiums of those whose income is 400 percent of the federal poverty level and below. Taxpayers would pay for this. But it would still mean that people who earn 200 percent to 400 percent of the federal poverty level would have to pay 8 to 12 percent of their income for private insurance premiums, or pay a fine and stay uninsured.

That would be the so-called “choice.” For the uninsured, paying for expensive insurance would amount to an enormous wage cut. And then they’ll get skimpy coverage, with high co-pays, high deductibles and all those other onerous and unworkable measures that come with very expensive private insurance.

One of the justifications that Obama and the Democrats used for these bills is that they will control the cost of health care. Are they telling the truth?

TOTAL HEALTH care spending will not be brought under control by either of these bills. It will not bend the cost curve. As health care costs continue to increase dramatically, the crisis of unaffordable health care will continue, for ourselves and our families, with increased out-of-pocket costs, new mandatory premium payments and ongoing medical bankruptcies, will remain acute.

What about the so-called public option? What impact will it have on the health care system?

THE PROPOSALS for the public option as they stand are meaningless from the point of view of reform, and ridiculous as a way to influence the insurance market. There are so many compromises, it might be renamed the incredible shrinking public option. And also, as a TV talking point, it has often eclipsed a focus on what’s really in the bill.

But I think that there’s more fundamental point. The public option was never a proposal for workable reform. It’s actually a neoliberal concept. Marie Gottschalk, a professor at the University of Pennsylvania, has written an article in the new Socialist Register 2010 entitled “U.S. Health Reform and the Stockholm Syndrome.”

She argues that when it comes to health reform, American reformers are like hostages who identify with, and even defend, their captors. I heard her speak in New York, where she said it seemed that if a window opened to permit real health reform, many “reformers” wouldn’t even try to climb out.

What do you mean that the public option is in fact a neoliberal proposal?

The public option idea is basically that the insurance market will will magically meet our needs, as long as there is consumer choice and fair competition. This is the ideology popularized by Ronald Reagan. If only a government agency could be added alongside these giant, highly profitable insurers with their oligopoly control, then the marketplace would magically reform itself. Does that make any sense?

The insurance market rewards insurers that avoid paying for the care of sick. The public option would have to play by the same rules and compete on the same market. So in the best-case scenario, the public option would tend to enroll the sickest patients, and, in turn, would have higher, not lower, expenses. The Congressional Budget Office recently made this very point in a report on the House bill.

So a successful public insurer next to the private companies might instead put us on the fast track to permanent two-tiered health care, a deplorable trend already well underway.

But most likely of all, if enacted, the public option would turn out nationally just as it has in Maine–a failure, not a reform. In Maine, a state-funded public insurance called DirigoChoice has been around since 2003. Since then, it has enrolled fewer than 10 percent of the uninsured, it has not done a thing to control costs, and this year, it faces a fiscal crisis that threatens its future existence

What impact will these bills have on the health care crisis?

IMMEDIATELY ON the passage of the bill, very little would change. There is some insurance regulation, but we should note that this is regulation the industry itself proposed.

For instance, the insurance companies will have to stop rescissions–arbitrary cancellation of policies that come usually with the “coincidence” of the patient getting sick. But they can still cancel policies if the policyholder commits “fraud”–or if you simply can’t pay your premiums. And over the decade, the insurers stand to gain tens of millions of new customers and hundreds of billions in taxpayer subsidies.

So I think that passage of the bill is virtually irrelevant to the everyday crisis. The main features in the House bill are not scheduled to start until 2013, and those in the Senate bill won’t start until 2014. Then it still won’t lessen disparities, or guarantee access to everyone, or improve the quality of care, or reduce costs. In fact, the main things in the bill have already failed at the state level, including the public option, including mandatory insurance.

For most people, health insurance will still be tied to their jobs, right?

Yes. When you lose your job, you will still lose your health insurance. Even worse, illness can lead to job loss and loss of insurance. Not just for the patient. If someone in your family gets very sick, the illness can cause you to miss work, too–going to appointments, to chemotherapy, waiting after surgery, coming home from the hospital, going to the pharmacy, going back to the hospital.

In such situations, people often lose their jobs in the United States. That’s the purpose of the Family Medical Leave Act. But even so, in our insane system, people lose their health insurance because they have no paycheck. These cruelties will remain a fact of life. Can we swallow such a bitter pill with a bit of tonic that more of the people who lose their jobs will now be eligible for Medicaid? I don’t think so.

Would it be better if no bill passes than one of the proposals in Congress today?

Single Payer New York, the coalition that I am a co-chair of, had a steering committee discussion a few months back. It was our opinion at that time that it would be better to keep arguing for single payer, and not take a position on a bill that hadn’t come out. More recently, Single Payer New York put out an unequivocal statement that recommends a “no” vote. We have also applauded Rep. Eric Massa of western New York for his principled vote against the House bill.

Personally, I think we should embrace any dialogue that advances the grassroots, kitchen-table debate about health care in this country.

The costs and hassles of health care are breaking working-class families. Prescriptions are not affordable, appointments can’t be had, our insurance is tied to our job or our spouse, millions of people are impacted by bankruptcy and Medicaid is a dis
aster. Too often, a personal crisis, health care amounts to an accumulating social crisis. The Democratic bills now in the Congress are no solution.

The single-payer movement had attracted Democratic support in the House for a bill known as HR 676 that would have established a single-payer system. Leaders among these Democrats promised that there would at least be votes on single payer. Why didn’t they deliver?

Forgive me for the long story here, but what happened this year was really remarkable and very positive. How many people are on full-time paid staff for single payer in the whole country? Less than a dozen or so, if that? Yet, there was a year of sustained mobilization, starting before Obama’s election, that grew and grew, from local, volunteer organizing.

The AFL-CIO convention passed a resolution this fall that endorsed single payer and the broader concept of social insurance, building on support for HR 676 within the unions. And then the Democratic Party leadership had to maneuver and spin all year long, trying to keep single payer off the table. These are a testament to the strength and energy of the grassroots inside and outside the AFL-CIO.

Back at the end of July, New York Congressman Anthony Weiner and six other HR 676 co-sponsors, brought into the Energy and Commerce Committee an amendment to substitute the text of HR 676 for the House bill. The leadership needed to get the main bill out of committee that day, the day before the summer recess. One day earlier, about a thousand people visited Congress and rallied outside the Capitol for single payer.

So while Nancy Pelosi and Henry Waxman, the committee chair, didn’t want to have a debate on single payer in the committee, neither could they simply push it aside. So Pelosi offered Weiner a deal. If he withdrew the amendment in committee, she would let him put it on the floor of the House for a debate and vote.

Weiner took the deal, but it was the single-payer grassroots who really called Nancy Pelosi’s bluff. We recognized that a floor vote–a losing vote–would be a historic precedent, not just that single payer would get to the floor of the House for the first time, but that the grassroots movement would be the force to put it there. Plus we hoped to see members of the House of Representatives stand for single payer and be counted. We wanted to know who our true friends were, with an eye on the 2010 elections.

So a campaign of lobbying, picketing and protesting commenced, from dozens of local organizations and a handful of national organizations. It brought to Congress hundreds of thousands of phone calls and faxes and e-mails, maybe millions–far more than anyone would have predicted. Protests grew vigorous. In fact, over 150 people were arrested in nonviolent civil disobedience actions at insurance companies and at congressional offices, including Nancy Pelosi’s San Francisco office.

Weiner, an ambitious guy, jumped in with a bit of pizzazz. He got on television, and at one point turned the tables on the interviewer by asking what it was that insurance companies added to health care. Single payer helped his stature. But the week that the House bill came up, Weiner published a piece on the Huffington Post that was all about the public option, with no mention of single payer.

Earlier, we had expressed our dismay because he wanted to change some of the HR 676 language to leave out the undocumented immigrants–changing “residents” to “citizens” in the amendment. On the other hand, to his credit, he worked to get his single-payer amendment to the floor up to the very end. And Pelosi never would have negotiated with Weiner without the grassroots heat, charming though Weiner might be.

In fact, the day before the vote, there was a full-page ad by the AFL-CIO and eight unions, including the California Nurses Association, in Roll Call calling for a “yes” vote on the Weiner Amendment. By this point, the Democratic Party leadership must have been surprised and frustrated that they had to keep finding new ways to keep single payer off the table. We heard rumors that even the White House had helped squelch the amendment vote.

In a curlicue twist, late on the Thursday before the Saturday House vote, Congressmen Dennis Kucinich and John Conyers together issued a letter saying that the Weiner amendment would be “tantamount to driving the movement over a cliff.” A losing vote for single payer on the House floor would hurt the cause, they said.

Their opinion stood in direct contradiction to the single-payer advocates who saw the efforts demanding the amendment as historic and imperative. Nancy Pelosi must have been overjoyed, for the letter gave her a new excuse to knock single payer off the table.

Pelosi also made an argument that in retrospect seems like pure chutzpah. She said that if a single-payer amendment came to the floor, she might also have to allow an amendment to restrict abortion rights to the floor. So we were to be mollified by the thought that if the single-payer amendment was withdrawn, at least women’s rights would be protected.

But we know how that turned out. We asked for health reform, and they gave us an abortion ban. Is that the true state of the Democratic Party today? To get the Democrats own “Blue Dog” right wing to vote for “health reform,” largely conceived and written by the insurance companies, they had to trade away women’s rights? Good grief.

Meanwhile, Kucinich had another amendment that would make it slightly easier for single payer to be enacted state by state. The Kucinich amendment came through the Education and Labor committee, where Kucinich got it passed with help from Republicans, but it wasn’t included in the bill. This amendment, too, was the focus of grassroots action–and is still.

He has since been fighting to get the state-by-state amendment back into the final legislation, with some success, getting the Progressive Caucus to endorse the idea. After Kucinich voted against bill, he issued a clear and powerful statement explaining his vote by saying the private insurance companies are the problem, not the solution.

What’s the lesson of this experience?

We just found out that Bernie Sanders will put a substitute single-payer amendment before the Senate, with at least two other senators promising to vote for it. But when the dust settled in the House, only two representatives, Dennis Kucinich and Eric Massa, voted against the bill because it wasn’t single payer. Two. The rest went with the Democratic Party leadership and voted for the bill–abortion ban and all. Evidently, this is what it means to be a progressive Democrat in Congress today.

It also tells us that we need to build a bigger grassroots movement. We are learning that the Democratic Representatives–and I daresay the Republicans, too–will respond to a grassroots mass movement, but we have to build that movement. No one will do it for us. As we do so, we must maintain our independence from elected officials. We have to continue to pressure them, sure–but our eyes should be on the grassroots, not the Democratic Party. I think that’s the most important lesson.

We might also remember that single payer will be won when it becomes a mainstream demand. So the goal of the movement should be to make our proposal the litmus test for the entire nation–left, right and center. The whole country simply must have a health system built upon the principle of solidarity. What other kind of society would we want to live in?

What’s the way forward for the single-payer movement?

What we need above all else is confidence. Our demand is popular, workable and just. We learned this year that there really is a social movement for single payer coming into being. We should be telling our advocates this: if you keep doing what you have been doing, we will win single payer. All year long, we have had the attention of the Congress and the White House. Much as they wanted to, they could not shake us.

It
‘s really up to us. We can build this movement. The health care crisis will persist in spite of the Democrats’ 10-year plan. With unemployment still rising and possibilities for a frank political crisis emerging, we might soon find a situation in which something has simply got to give. We need to learn to articulate broader benefits of single-payer reform as an economic rescue and as personal liberation for working people.

Our grassroots single-payer movement will also grow by learning to fight on related issues. For example, in Braddock, Pa., the western Pennsylvania single-payer activists have gotten involved in defending a community hospital from closing. The University of Pittsburgh Medical Center–itself an insurance company by the way, and a massive corporation with a millionaire CEO–bought up the health care infrastructure in the area, including Braddock Hospital.

If we had single payer, we wouldn’t have this corporate medicine, building a new hospital in the wealthy suburb and closing the hospital in the old city. If we had single payer, health care priorities would be planned to meet the needs of the community, not the corporate bottom line.

The single-payer movement needs to join local struggles like this one and articulate how single payer would help solve these problems. That’s how we will be able to forge out of a nascent movement a force that can overwhelm the opposition to single payer in Washington, D.C.

Medicare buy-in?

Harry Reid: Democrats reach ‘broad agreement’

By Carrie Budoff Brown & Patrick O’Connor
Politico
December 9, 2009
Senate Democrats have reached a “broad agreement” on a health reform bill, Majority Leader Harry Reid said Tuesday night — a plan that would replace the public option in the current Senate bill with a new national insurance plan offered by private insurers, and a chance for older Americans to “buy in” to Medicare.
To win over liberals disappointed at losing the public option, Democrats would allow older Americans starting at age 55 to buy into Medicare, the popular program for the aged. The Medicare expansion would be a significant victory for Democrats, who spent years pushing for it. The proposal would in effect create a public health insurance option for older Americans, since Medicare is government-funded and government-run.
http://www.politico.com/news/stories/1209/30371.html

The most efficient, most effective, and least expensive method of providing reasonably comprehensive health care for everyone would be to replace all current public and private financing programs with a single, improved Medicare program that covered absolutely everyone. Some have suggested that we can do this incrementally, with the first step being to allow individuals 55 and over to buy into Medicare. Is this a good idea?
Harvard professor Steffie Woolhandler provides us with some insight: “Lowering the eligibility age for Medicare to 55 only works if it is mandatory. Otherwise it becomes the place where all the sickest patients get dumped. That might be okay for the sick people since Medicare is often better and more secure than private coverage, but it would drive total health care costs (and premiums) up, not down.”
The current Medicare risk pool is composed of seniors with a high rate of chronic disease and with the expenses of end-of-life care, plus younger individuals with long-term disabilities. Since this is a very high cost population, the prorated premiums would be unaffordable for most individuals 55 thru 64. A separate risk pool would have to be established that would be limited to this age bracket. Unfortunately, 55 thru 64 is still the most expensive age sector of all individuals under 65 and so premiums would still be unaffordable for most, especially after you add in the impact of adverse selection as Steffie Woolhandler has described.
Suppose that a Medicare buy-in for those over 55 were to be established, and that higher government subsidies were provided to cover the higher costs, then what do you have? You have created a public option. Yet the reason being given for the Medicare buy-in is that it is a trade-off to get the progressives to agree to abandoning the public option.
So the agreement seems to be to eliminate the public option from consideration by establishing a public option. But is the proposal a public option that would allow everyone the opportunity to buy into Medicare? Apparently not. After all, this is Congress at work.
Although details have not been released, it appears that this Medicare buy-in would be limited by the same rules already proposed for the public option. Individuals who already are eligible for employer-sponsored coverage, Medicare, or Medicaid would not be eligible to participate in the insurance exchange, yet the Medicare buy-in would not be available outside of the exchange (except perhaps during a transition before the exchange is established). Thus the net effect of this buy-in is to further limit the public option only to those 55 and over who meet all other qualifications for the exchange – a ratcheted-down version of the public option.
An elective buy-in for Medicare will only add to the perpetuation of inequities, fragmentation, administrative inefficiencies, inadequate fiscal supervision and other deficiencies that plague our health care financing system. Adding to our dysfunctional system only compounds the dysfunction. We need to replace the system with an efficient single payer model.
Could we do that in incremental steps by first moving absolutely everyone over 55 into our existing Medicare program? Yes, but why would we do that? There would be complex transitional issues in changing this sector from a revenue source for Medicare into both a revenue source and an expense as they become beneficiaries of the program. Another increment could be MediKids for all children, though that would involve other transitional issues. Then how soon would we phase in everyone else, with yet still more transitional issues?
Incremental steps increase the complexities and costs of the transition while delaying access for many who already have impaired access and financial burdens caused by our dysfunctional system.
A single, disruptive transition would actually be more efficient administratively, while lowering transitional costs. Much more important, a single transition would ensure that no person would have to wait any longer to access the care that he or she needs merely because of an inability to pay for that care.
If we advocate for less than we need, we’ll end up with cheap chits that will eventually be traded away, and then what are we left with?

Here Come the Apologists

Yes, This Health Care Bill Really is Worse Than Nothing

By HELEN REDMOND
Counterpunch, December 8, 2009

If you join a fight for social justice you many win or lose, but just by being part of the struggle, you win, and your life will be better for it.

–Howard Zinn

Already defenders and apologists for the Democrat’s health care legislation are busy at work. In the next few weeks they will be working overtime to persuade, cajole, shame and ruthlessly attack if necessary, anyone opposing health care legislation. They’ll reserve special hysteria, invective and contempt for those of us who continue to support a single-payer, national health care system.  And because it is the holiday season, we will be called heartless health care Grinches and silly, single payer, Bernie Sanders Scrooges. There will be accusations: “If you don’t support health care reform legislation, you support the status quo.” Implicit in the indictment is single-payer advocates, with their pie-in-the-sky idea that health care is a human right for all, will be responsible for the continued impoverishment and immiseration of the American people if a bill doesn’t pass.

Joshua Holland, an editor and senior writer for AlterNet and Uwe E. Reinhardt, an economics professor at Princeton, have begun the onslaught.
In a piece posted on AlterNet November, 24th titled, “Is the House’s Health Bill Really Worse than Nothing?” Holland attacks Dr. Marcia Angell, author, former editor of the New England Journal of Medicine and a leader of Physicians for a National Health Program (PNHP.) Dr. Angell opposes the House bill and believes it’s “worse than nothing.” For that she earns the disdain of Joshua who just can’t accept there isn’t something in the bill worth supporting, even though he agrees with her trenchant criticism of the bill’s gaping defects. He claims she ignores the “primary thrust of the legislation” which for Holland is “the fact that the House legislation would do quite a bit for millions of real Americans struggling through a very real health care crisis.” “Real” Americans, a “real” health care crisis? The insinuation is Angell, and by affiliation PNHP, isn’t operating in the real world of real suffering if they don’t support whatever bill Congress delivers to the Oval Office for a signature. That’s interesting. An organization of 16,000 doctors that conducts research on major aspects of the health care crisis and have been on the frontlines for real reform for decades doesn’t understand what’s real?

Holland argues Angell negates her original thesis when she writes, “The bill has a few good provisions (expansion of Medicaid, for example) but they are marginal.” It doesn’t. Her central contention is even with an expansion of Medicaid and a few other “good” provisions, the bill is a bomb because on balance, it entrenches the power and profits of the private insurance industry – the source of the health care crisis.

This isn’t the first time an expansion of Medicaid has been offered as a partial panacea for the health care crisis. And it has to be said: It isn’t necessary to create a huge, complex and expensive piece of national legislation in order to expand the Medicaid Program. Any state can decide at any time to change eligibility rules and insure more residents (Massachusetts did in 2006.) But the overall trend has been the opposite.

According to a study published in the Annals of Family Medicine, “Medicaid programs in all 50 states implemented cost-savings strategies, including benefit reductions, cost sharing and tightened administrative rules during the recent economic downturn.” Medicaid operates within the dysfunctional, multi-payer health care system and has suffered from an expand-contract cycle since its inception. It’s a favorite target for blame-the-victim politicians who want to get poor people off welfare (and health care) and into the workforce with no health care. Under the Clinton Administration’s “welfare reform,” hundreds-of-thousands of mostly women and children lost Medicaid coverage. The Medicaid program is not an entitlement or a right. An onerous redetermination is done every year in most states. And in fact, losing Medicaid coverage for a variety of reasons is the norm.

It’s true – the expansion of Medicaid would help millions of low-income Americans, but for how long? Expansion of Medicaid is a short-term, incremental fix, not a permanent one. And that should be the goal of legislation – a permanent fix to the health care crisis so there is no longer a health care crisis. 

Holland thinks the subsidies are “rather generous.” It’s curious he isn’t asking these questions: If the government were truly reforming health care, why would millions of people need subsidies? Shouldn’t the cost of coverage come down so much its affordable without government assistance?

Here’s the conundrum – if you support subsidies to help people buy insurance and the expansion of Medicaid, you are forced to support the transfer of billions of taxpayer dollars into the coffers of the investor-owned insurance industry and a mandate that criminalizes and punishes people. You also have to accept the Stupak Amendment and the denial of health care to millions of undocumented workers.

There are more poison pills to swallow. Holland thinks it’s fine insurance will still be linked to employment – tell that to the millions who are unemployed and being laid off by the thousands every day. In the House bill, if employers offer insurance, they must pay at least 72.5 percent of the premium for individuals and 65 percent for families. That’s too low and gives companies who pay a higher percentage an incentive to shift costs onto employees until they hit the government-mandated limit. Workers will then be dumped into the insurance exchange because it will be cheaper for employers and once there, because of the mandate, forced to buy stripped down plans with no limits on premiums.

Currently, there are over twenty-five million people underinsured. The majority of people who declared medical bankruptcy started out with insurance. That is the wave of the future. The government will claim more people are insured and technically they will be, but are you really insured if you have a $5000 deductible, high co-pays and less than one-hundred percent coverage for hospitalizations, expensive medication and diagnostic tests?

And what about the much ballyhooed public option which was supposed to keep the rapacious insurers honest and give millions quality, inexpensive health care that Joshua argued for at the expense of advocating for single-payer which he is a supporter of? Eviscerated, not robust at all, and what Paul Krugman now calls “medium-strength.” It’s not even that. The “progressive” Democrats abandoned Holland and his ilk and voted in favor of the bill after they swore not to if it didn’t contain a robust public option with rates tied to Medicare. These are the same “regressive” Democrats that voted in favor of the Stupak Amendment. Holland argues if the final legislation contains Stupak it can’t be supported. But if “Progressive-Regressive” Democrats voted for it the first time, they will vote for it a second time because they don’t have the spines to stand up to President Obama, or for abortion rights.         

Toward the end of his assault on Dr. Angell’s position, Holland writes, “…drawing the line at the House bill is privileging ideology over getting something done in the short-term, however imperfect it might be overall.” But that is precisely the problem. For decades short-term, imperfect reforms are offered that inexorably lead right back to the crisis. Then more short-term, imperfect reforms are offered and the cycle continues. Instead of attacking the p
rivileged ideology of for-profit, corporate controlled health care, Joshua attacks single-payer ideology and argues to abandon it in order to get something, anything done.

Single-payer supporters also reject his false choice of “trying to push for the best package possible or leaving a disastrous status quo in place…” The not so subtle message is if a bill doesn’t pass we will be responsible for the disastrous status quo that is the state of health care in this country. Sorry Joshua, but that responsibility will rest with the Obama Administration that at every turn placated the profit hungry, parasitic insurance and pharmaceutical industries.

And if a bill does pass this year, we can hurry up and wait 4 years because that’s when it will be enacted! So, disastrous status quo for 4 more years, then in 2013 implementation of a disastrous bill that will continue to leave 20 million uninsured. I can hardly wait. 

Uwe E. Reinhardt dismisses and disrespects Dr. Don McCanne, another leader of PNHP, for arguing current health care legislation can’t be supported and instead the fight for a single-payer health care system must continue.

Reinhardt wrote in response to Dr. McCanne’s comments on the letter he and 22 other prominent economists sent to President Obama: “Don is a mensch, but a dreamer. Let’s face it, this very limited bill, should it pass into law, is the very best Americans can hope for. This country will never have a sensible, efficient health care system, and perhaps not even a totally humane one. For better or worse, we must get used to it.”

Reinhardt’s work is full of contradictions. He writes extensively on health care and understands that a government-run, single-payer system is the best way to control the cost of health care and insure everyone. Like in Taiwan. But Reinhardt is thoroughly pessimistic the political movement that is necessary to bring about that kind of system can be built and can win. So he tells us we have to get used to 45 thousand people dying every year for lack of health care. We have to get used to millions of families being bankrupted from medical bills. It’s the very best Americans can hope for and if you don’t hope for that you are a stupid dreamer. I couldn’t disagree with Dr. Reinhardt more. We cannot and will not get used to that barbarism.
Obviously Reinhardt hasn’t been paying attention to the movement for single-payer and what we have accomplished during this round in the health care debate.  

Reinhardt needs to come down from his Ivy Tower and join the movement for single-payer. It’s really not so bad down here at the grassroots level, Uwe. There is PNHP with 16,000 members. The California Nurses Association (CNA) supports single-payer and has thousands of members, too. Sections of the labor movement support single-payer. There are grassroots, single-payer organizations in almost every state with committed members who got arrested in acts of civil disobedience at insurance company headquarters. And poll after poll consistently shows the majority of Americans want government-run, guaranteed and financed health care.

If Reinhardt came over strongly and unequivocally to the side of single-payer, he could help the movement take a giant step closer to winning a humane, efficient health care system. He could use his prodigious talents of number crunching and economic analysis to demonstrate the superiority of single-payer and to demoralize and defeat The Powers That Be who listen to his economic prognostications on health care reform. Reinhardt could be a founding member of an organization of economists for single-payer and name it Economists for Single-Payer Network (ESPN.) He could be a proud member of a social movement struggling to make health care a human right in the richest capitalist country in the world.

Helen Redmond, LCSW, is a medical social worker in Chicago. She can be reached at redmondmadrid@yahoo.com. She blogs at http://helenredmond.wordpress.com  

http://www.counterpunch.org/redmond12082009.html

U.S. nurses unions merge, back healthcare overhaul

Merger forms largest union of medical professionals

By Tim Gaynor
Reuters, Dec 7 2009

Three nurses unions merged on Monday to form the largest-ever labor organization for U.S. medical professionals, which is expected to wield greater clout in collective bargaining and the national healthcare debate.

Leaders of the new 150,000-member National Nurses United, comprising union locals from Maine to Hawaii, said their top priority would be to seek to organize the overwhelming majority of registered nurses who remain without union representation.

Of roughly 1.5 million nurses who provide direct patient care in U.S. hospitals and clinics, about 80 percent have no union contract, NNU officials said.

The merger, approved unanimously by delegates to the founding convention in Phoenix, unifies the California Nurses Association, with 83,000 members in California and several other states; the United American Nurses, with 45,000 members, mostly the Midwest, and the 22,000-member Massachusetts Nurses Association.

The move comes as President Barack Obama is battling to rally support for his top domestic priority, an overhaul of the U.S. healthcare system that extends coverage to millions of uninsured people and curtails spiraling costs.

He faces sharp divisions among lawmakers in the Democratic-controlled Congress over his proposal for a new government-run insurance plan, or public option, an approach fiercely opposed by Republicans and private health insurers.

NURSES SEEK STRONGER HEALTH OVERHAUL

Deborah Burger, president of the California nurses group, said the merger would likely lend powerful support for the more progressive aims of the overhaul, but she said Obama’s plan would not go far enough.

“What we’ve got now isn’t really healthcare reform, it’s a reshuffling of the deck chairs on the Titanic as far as our patients are concerned, and we’re going to make sure that we … have universal healthcare that is truly universal and has eliminated the insurance companies,” she told Reuters.

Aside from a bigger voice in the healthcare debate, the merger is expected to give nurses greater leverage in collective bargaining after decades of growth in national hospital chains that have largely resisted union organizing.

The labor movement sees an opportunity to bolster its ranks in the healthcare industry, a sector that has continued to create jobs during the recession and is expected to see 20 percent employment growth above 2006 levels by 2016, according to U.S. Labor Department statistics.

“This is where the jobs of the future lie,” said Chris Tilly, director of the Institute for Research on Labor and Employment at the University of California, Los Angeles.

“Baby boomers like me are aging and will soon need a lot of nurses, so this is an area where there’s going to be a lot of expansion. There’s going to be a lot of hard political decisions to make,” he said.

Plans to organize nonunion nurses go hand-in-hand with ongoing efforts to end mandatory overtime for nurses and other cost-cutting hospital practices that nursing advocates say have stretched patient care too thin.

The focus on patient care also figures in the union’s aim to seek passage of federal legislation setting national standards for nurse staffing levels.

Dian Palmer, president of the Nurse Alliance of the Service Employees International Union, which represents 85,000 nurses, hailed the merger of the three unions, saying it would help “ensure the delivery of safe, quality care for everyone in our country.” (Additional reporting by Steve Gorman in Los Angeles, editing by Chris Wilson)

$126,000 drug that only makes the desperate sick

Questioning a $30,000-a-Month Cancer Drug

By Andrew Pollack
The New York Times
December 4, 2009

A newly approved chemotherapy drug will cost about $30,000 a month, a sign that the prices of cancer medicines are continuing to rise despite growing concern about health care costs.

Critics, including many oncologists, say that patients and the health system cannot afford to pay huge prices for drugs that, on average, provide only a few extra months of life at best.

And Folotyn (made by Allos Therapeutics) has not even been shown to prolong lives — only to shrink tumors. The drug was approved by the Food and Drug Administration in late September as a treatment for peripheral T-cell lymphoma, a rare and usually aggressive blood cancer that strikes an estimated 5,600 Americans each year.

(James V. Caruso, the chief commercial officer for Allos) said the price of Folotyn was not out of line with that of other drugs for rare cancers. Patients, moreover, are likely to use the drug for only a couple of months because the tumor worsens so quickly, he said.

In a note to clients in October, Joshua Schimmer, an analyst at Leerink Swann, estimated that a typical treatment would last 3.5 months and cost $126,000, or about $36,000 a month.

http://www.nytimes.com/2009/12/05/health/05drug.html?_r=1&hpw

And…

Prescribing Information for Folotyn (pralatrexate injection)

Allos Therapeutics, Inc.
Issued: September 2009

Indications and Usage:

Folotyn is indicated for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL). This indication is based on overall response rate. Clinical benefit such as improvement in progression free survival or overall survival has not been demonstrated.

Adverse reactions (list includes only those events occurring in 10 percent or more of patients treated):

Mucositis
Thrombocytopenia
Nausea
Fatigue
Anemia
Constipation
Pyrexia
Edema
Cough
Epistaxis
Vomiting
Neutopenia
Diarrhea
Dyspnea
Anorexia
Hypokalemia
Rash
Pruritis
Pharyngolaryngeal pain
Liver function test abnormal
Abdominal pain
Pain in extremity
Back pain
Leukopenia
Night sweats
Asthenia
Tachycardia
Upper respiratory tract infection

Percent of patients experiencing any adverse event: 100 percent

Forty-four percent of patients (n = 49) experienced a serious adverse event while on study or within 30 days after their last dose of Folotyn.

http://www.folotyn.com/pdf/package-insert.pdf

And…

Patient Protection and Affordable Care Act (Amendment in Senate)

The Library of Congress, THOMAS
H.R.3590

Title VII – Improving access to innovative medical therapies
Sec. 7002, (a), (2), (k)
(7) Exclusivity for reference product
(A) Effective date of biosimilar application approval – Approval of an application under this subsection may not be made effective by the Secretary until the date that is 12 years after the date on which the reference product was first licensed under subsection (a).

http://thomas.loc.gov/

Comment:

By Don McCanne, MD

Fotolyn is a new miracle drug brought to us by our highly revered pharmaceutical industry. This new drug has no demonstrated clinical benefit, though all patients have adverse reactions, almost half of them serious – including death.

In an astonishing moment of candor, James Caruso, chief commercial officer for Allos, provided reassurance that the very high monthly cost of Fotolyn would not be protracted since the tumor worsens so quickly.

What makes this drug a miracle only the investment community can understand. Desperate patients will spend an average of $126,000 for this worthless drug. On Wall Street that’s a miracle, but within the health policy community, that’s a tragedy.

You can be assured that, in crafting health care reform, Congress has responded to the very high prices of newer patented therapeutic agents, but in a perverse way. Recognizing the great potential of genetically-engineered biologics, Congress has included in the legislation an unprecedented 12 year exclusivity, protecting the firms from competition of biosimilar products.

Maybe the biotech firms will be able to parley this into seven-figure treatment programs for the desperately ill. The soak-the-sick policies may not work for patients, but they certainly work well for Wall Street. And doesn’t that seem to be where Congress’s loyalties lie these days?

$126,000 drug that only makes the desperate sick

Questioning a $30,000-a-Month Cancer Drug

By Andrew Pollack
The New York Times
December 4, 2009
A newly approved chemotherapy drug will cost about $30,000 a month, a sign that the prices of cancer medicines are continuing to rise despite growing concern about health care costs.
Critics, including many oncologists, say that patients and the health system cannot afford to pay huge prices for drugs that, on average, provide only a few extra months of life at best.
And Folotyn (made by Allos Therapeutics) has not even been shown to prolong lives — only to shrink tumors. The drug was approved by the Food and Drug Administration in late September as a treatment for peripheral T-cell lymphoma, a rare and usually aggressive blood cancer that strikes an estimated 5,600 Americans each year.
(James V. Caruso, the chief commercial officer for Allos) said the price of Folotyn was not out of line with that of other drugs for rare cancers. Patients, moreover, are likely to use the drug for only a couple of months because the tumor worsens so quickly, he said.
In a note to clients in October, Joshua Schimmer, an analyst at Leerink Swann, estimated that a typical treatment would last 3.5 months and cost $126,000, or about $36,000 a month.
http://www.nytimes.com/2009/12/05/health/05drug.html?_r=1&hpw

And…

Prescribing Information for Folotyn (pralatrexate injection)

Allos Therapeutics, Inc.
Issued: September 2009
Indications and Usage:
Folotyn is indicated for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL). This indication is based on overall response rate. Clinical benefit such as improvement in progression free survival or overall survival has not been demonstrated.
Adverse reactions (list includes only those events occurring in 10 percent or more of patients treated):
Mucositis
Thrombocytopenia
Nausea
Fatigue
Anemia
Constipation
Pyrexia
Edema
Cough
Epistaxis
Vomiting
Neutopenia
Diarrhea
Dyspnea
Anorexia
Hypokalemia
Rash
Pruritis
Pharyngolaryngeal pain
Liver function test abnormal
Abdominal pain
Pain in extremity
Back pain
Leukopenia
Night sweats
Asthenia
Tachycardia
Upper respiratory tract infection
Percent of patients experiencing any adverse event: 100 percent
Forty-four percent of patients (n = 49) experienced a serious adverse event while on study or within 30 days after their last dose of Folotyn.
http://www.folotyn.com/pdf/package-insert.pdf

And…

Patient Protection and Affordable Care Act (Amendment in Senate)

The Library of Congress, THOMAS
H.R.3590
Title VII – Improving access to innovative medical therapies
Sec. 7002, (a), (2), (k)
(7) Exclusivity for reference product
(A) Effective date of biosimilar application approval – Approval of an application under this subsection may not be made effective by the Secretary until the date that is 12 years after the date on which the reference product was first licensed under subsection (a).
http://thomas.loc.gov/

Fotolyn is a new miracle drug brought to us by our highly revered pharmaceutical industry. This new drug has no demonstrated clinical benefit, though all patients have adverse reactions, almost half of them serious – including death.
In an astonishing moment of candor, James Caruso, chief commercial officer for Allos, provided reassurance that the very high monthly cost of Fotolyn would not be protracted since the tumor worsens so quickly.
What makes this drug a miracle only the investment community can understand. Desperate patients will spend an average of $126,000 for this worthless drug. On Wall Street that’s a miracle, but within the health policy community, that’s a tragedy.
You can be assured that, in crafting health care reform, Congress has responded to the very high prices of newer patented therapeutic agents, but in a perverse way. Recognizing the great potential of genetically-engineered biologics, Congress has included in the legislation an unprecedented 12 year exclusivity, protecting the firms from competition of biosimilar products.
Maybe the biotech firms will be able to parley this into seven-figure treatment programs for the desperately ill. The soak-the-sick policies may not work for patients, but they certainly work well for Wall Street. And doesn’t that seem to be where Congress’s loyalties lie these days?

Health Care Should Be Driven by Mission, Not Money

By Philip Caper
Published on Wednesday, December 2, 2009 by CommonDreams.org

As health care reform legislation enters a critical phase in Congress, it’s important to keep our eye on the ball — elements essential to the success of any reform effort. In order to define those elements, we must have a clear understanding of the nature of the pathology in our dysfunctional health care system.

Modern high tech health care is a right of the residents of most wealthy countries in the world — except the United States. America is exceptional in this regard. It is also exceptional in being the only wealthy nation where health care is considered to be a business.

Prior to about the mid-1970s, American health care institutions like those in other developed countries were overwhelmingly non-profit locally controlled entities driven by their mission — comforting the sick, curing illness, and promoting healing.

Most physicians practiced independently or in small groups, free to carry out their Hippocratic oath. Hospitals were community based non-profit institutions governed by local volunteer boards. Private insurance companies were also mostly non-profit, and rarely crossed state lines. Pharmaceutical companies were small, often family owned and mostly driven by George Merck’s ethic: “If we develop medicines that cure disease, the money will take care of itself.”

In the mid-1970s, leaders in American health care fell in love with business. They began to believe that management could be improved and costs controlled by a stiff dose of good old American business know-how. As a result, first MBAs and then full-fledged corporatism began to engulf and transform medical care. Hospital administrators became CEOs, services became product lines, patients became market share and so on.

Hospitals consolidated and became part of larger networks. Local control was weakened or lost. Insurance companies consolidated across state lines, and ownership was transferred from non-profit local corporations to for-profit multi-state and national corporations. As pharmaceuticals became a larger part of medical care pharmaceutical companies grew, became more profitable and merged, eventually creating huge multi-national conglomerates. Ownership was transferred from private (often family) hands to distant shareholders through lucrative public offerings. Health care products and services became just another commodity to be traded on the stock exchange — their value judged only in terms of return on shareholder on investment.

The practice of medicine, the bedrock of any modern health care system, changed too. Doctors went from being independent professionals, bound only by their Hippocratic oath, to being employees of increasingly large corporate entities, many of them also for-profit. As a result, physicians have come under growing pressure to tailor their clinical decisions to the revenue and profit demands of their corporate employers. These demands often conflict with the profit driven demands of insurers, attempting to maximize their profits by minimizing their “medical losses.” Revenue driven medical care was born. This profit-driven micromanagement of physicians’ decisions about how to treat their patients exists nowhere else in the world. It too is uniquely American.

As a result of these structural changes, the mission of the American health care system changed. Increasing shareholder value became the driving force in the financing and provision of medical services. In the process, the healing mission of medical care has been diminished and sometimes lost altogether. This too is a uniquely American phenomenon.

In order to resuscitate the healing mission of medicine, a few very important changes must be made to drive the profit motive out of the financing and direct provision of health care. They must be a dominant part of any successful reform effort.

The first step must be the strengthening of our publicly controlled non-profit system of financing medical care. From a policy perspective, the simplest and most direct way to do that would be to gradually expand Medicare. Medicare is effective, efficient and popular. The eligibility age could initially be dropped to 55, and then gradually lowered to eventually encompass the entire population. Unfortunately this fair, simple and elegant solution is also the most politically difficult due to the enormous influence of the medical-industrial complex on our politicians.

The second step must be to remove the profit motive from the direct provision of health care services by changing the way doctors, hospitals and other providers are paid. We must eliminate the fee for service system, and move toward global budgets for hospitals, and salaries and bonuses for doctors. This would remove the influence of fees for individual services on clinical decisions and would eliminate the single largest driver of exploding costs in American health care. It would also allow the incomes of primary caregivers to be brought closer to those of specialists and stem the exodus of doctors out of primary care practice. Higher incomes for primary caregivers relative to specialists would be justified by their role in managing the use of specialists and expensive tests and procedures.

Third, we must greatly strengthen the ability of our public insurance system to control the prices of pharmaceuticals and medical devices to bring the US more in line with all other developed countries. These companies are entitled to a fair profit but not the windfalls they are currently receiving due to the market protection they enjoy from federal patents, protection from price negotiations by Medicare and the massive public investment in biomedical research that often forms the basis of pharmaceutical products.

Health care reform without these basic changes is probably not worth doing, as it would simply reinforce the existing dysfunctional system. If these changes are part of reform, we will be on the way to joining other civilized countries in making health care a right of all our people. If not, it will continue to be an increasingly expensive commodity that only the wealthy can afford.

Philip Caper is a medical doctor who, in the 1970s, worked on the staff the late Senator Edward Kennedy, when the senator chaired the Senate’s health committee. From that time on, he has been a careful observer of health care politics in the United States.

http://www.commondreams.org/view/2009/12/02-8

250,000 FEHBP-eligible federal employees uninsured

How health care bills compare to lawmakers' plan

By Ricardo Alonso-Zaldivar
The Washington Post
December 6, 2009

You should get the same health insurance deal that members of Congress get. That was the gist of President Barack Obama’s message as he tried to drum up enthusiasm for his health care overhaul.

Government workers and members of Congress belong to the nation’s largest employer-sponsored health plan, covering 8 million employees, dependents and retirees.

“We estimate there are about 250,000 federal employees who are uninsured. They’re eligible, but they can’t afford the premiums,” said Jacqueline Simon, policy director for the American Federation of Government Employees.

http://www.washingtonpost.com/wp-dyn/content/article/2009/12/06/AR2009120601136.html

And…

New Government-Run Health Proposal Eyed

Democrats, in Search of Compromise, Explore Federal Employee Plan as a Model

By Greg Hitt And Janet Adamy
The Wall Street Journal
December 7, 2009

Democrats on both sides of the issue who were assigned by Sen. Reid to find a compromise were nearing agreement on an alternative that would empower the government’s Office of Personnel Management to run a new national health plan, congressional aides said. The office already oversees the federal employee health plan, and administration officials have pointed to it as an example of how the government can successfully run a health-insurance program.

Under the proposal, the office would negotiate terms of the plan with private insurers, and contract with nonprofit entities set up by the private sector to run the program, aides said.

http://online.wsj.com/article/SB126004745673278523.html

And…

Federal Employees Health Benefits Program (FEHBP)

American Federation of Government Employees
February 9, 2009

FEHBP has both structural and political flaws.

Those who must rely upon FEHBP for health insurance know its flaws well, and consider it anything but a model.

An estimated quarter of a million federal workers and their families are uninsured because FEHBP premiums are unaffordable to them on their modest federal salaries.  The continued cost-shifting only increases the ranks of uninsured and underinsured Americans.

http://www.afge.org/index.cfm?page=2009ConferenceIssuePapers&Fuse=Content&ContentID=1742

Comment:

By Don McCanne, MD

Why shouldn’t we all have the same insurance that members of Congress have? They and all other federal employees are covered by the Federal Employees Health Benefits Program (FEHBP), an exchange of private health plans from which they can choose their coverage.

The FEHBP plans share many of the problems found in private health plans marketed to non-government employers. Simply the fact that a quarter million federal workers and their families remain uninsured, though eligible for FEHBP, demonstrates that it is a flawed program that should be rejected as a model for reform.

For those who say that subsidies would make the difference, these federal employees have already been offered subsidies in the form of the federal employer contribution to their premiums, yet they still can’t afford their share of the premium. Besides, because insurance is available through their employment, they would not be eligible for the subsidized exchange plans anyway.

So what is Congress doing? Because of the political impasse over a public plan to be offered as an option to private plans within the insurance exchange, senators are currently advocating for the compromise of a separate exchange of private plans modeled on FEHBP. This model allegedly would satisfy the moderates opposed to the public option because it would be limited to private, non-profit insurers, and allegedly would satisfy the progressives because they could claim that it’s like the government insurance that members of Congress have. Of course there’s nothing government about it.

What is more ridiculous is the structure of this phony public option. It would establish an exchange of private insurance plans within an exchange of private insurance plans with a market of private insurance plans outside of the exchanges. What insurer is going to compete against its successful plans on the open market by offering competing plans in the insurance exchange and then competing with its plans in the exchange by offering plans in the exchange within the exchange?

Besides, how many truly dominant insurers are there? They constitute an oligopoly. Just as they play by their own market rules now, they will continue to do so even if modified by guaranteed issue or whatever.

Ask those 250,000 uninsured federal workers who were promised the coverage that members of Congress have what they think about FEHBP. Then ask them if they would like to have Medicare paid for by equitable taxes they can afford rather than by premiums they can’t afford. Then ask them to march on Congress!

Will reform bill help my patients? I'm skeptical

Big money wasted on insurer subsidies

By ROB KIEFNER
Concord (N.H.) Monitor, Dec. 4, 2009

Amid chaos, misinformation and misunderstanding, the health care reform bill was nudged through the House of Representatives by the narrowest of margins. By not letting the facts get in the way of their blustering arguments, wacky lawmakers from both sides of the aisle offered lots of hype and heft, at times bench pressing the actual 2,100-page document to underscore the strength of their positions.

I thought, for a time, that outcome would be decided by virtue of which representative’s head exploded first in a display of feigned indignation about one aspect or another of the bill.

As a family physician, I rely upon my patients’ stories for insight into health care reform. Lost in the mind-numbing mumbo-jumbo from Capitol Hill are the stories of real patients who can’t afford insurance and small business owners who can’t offer it. The House legislation might make insurance available to my patient who is a struggling small business owner, but at an impossible cost. To add insult to injury, he’ll be fined if he doesn’t purchase insurance.

And for those patients who have “decent” insurance, there are always the struggles, which we share as their doctors, to obtain the diagnostic testing and therapeutic treatments to which they are entitled. By keeping the for-profit insurance companies happy, the legislation will continue to effect de facto rationing of health services by employing the hassle factor.

Good faith?

The costs associated with this bill are not at all clear. If projections are tied in to the “good faith” cuts promised by the pharmaceutical and insurance industries last summer, we are indeed in trouble.

We spend twice as much on health care, per capita, as any other industrialized nation. Yet by several measures of our collective health and wellness, we rank a piddling 37th in the world.

The House bill, with mega subsidies to the health insurance industry, seems to assure our place as No. 1 in the world – for health care spending that is. Within that 2,000-page tome is a mandate for universal coverage with all sorts of befuddling caveats. While health insurers will have to take on patients with preexisting conditions, they’ll do just fine with the increase in volume of patients and the ability to increase premiums. Those insurance execs are kicking back, popping another magnum of Dom Perignon, and reveling in their ability to influence people in high places. Money well spent.

Now I’m not a rocket surgeon, but I think that we can achieve close to universal coverage by developing a publicly financed, privately delivered system in which the 30 cents of each health care dollar currently wasted on insurance companies is channeled into actual health care. In the context of a single-payer plan, or “Medicare for All,” nobody dies for lack of insurance or goes bankrupt on account of medical bills.

Primary care is key

Health care financing is but one leg of the table of reform. An equally important support is primary care. By enhancing the financing of primary care training programs and assuring that reimbursements are commensurate with the costs of providing services, we’ll close in on the quality gap with countries such as France, Germany and Switzerland. Time and again, studies have shown that regions of the country well served by primary care and preventive medicine experience decreased costs across the board, with fewer expenditures due to excessive testing and hospitalizations.

The final two pillars holding up the table of reform are the general acceptance of evidence-based medicine and malpractice reform. We should not be paying for expensive and ineffective diagnostic procedures and treatments, though I do believe that guidelines, and not mandates, are reasonable to allow physicians some leeway in the management of challenging clinical scenarios.

By definition, evidence-based recommendations are a work in progress. The use of screening mammograms among women under 50 has saved countless lives, and this practice should not be abandoned or even modified until much longer-term studies are available. As with any procedure in medicine, patients need to be fully apprised of the risks versus benefits of cancer screening tests.

By practicing in accordance with good science and not speculation, we should be able to diminish the onerous burden of defensive medicine costs.

This brings me to the fourth leg supporting the table: tort reform, conspicuously absent from the House bill. Honest oversight, or a function of the millions of dollars thrown at Democratic congressional campaigns by trial lawyers? Now that’s a tough one.

Focus on doctors

As our elected officials preen and posture for the next part of reform’s journey through the Senate, it is important to remember that governments and insurance companies don’t deliver health care.

It is health care providers and hospitals, working with patients who are fortified with a sense of personal responsibility, that will ultimately control costs and improve care.

Though I do hope that some form of reform ultimately passes, I am concerned that this bill, like “Hillary Care” so many years ago, is destined to collapse from its own incomprehensible mass.

(Rob Kiefner is a family physician in Concord.)

http://www.concordmonitor.com/apps/pbcs.dll/article?AID=/20091204/OPINION/912040357