PNHP

CBO: Few Americans Would Sign Up For Public Health Insurance Plan

CBO: Few Americans Would Sign Up For Public Health Insurance Plan

Kaiser Daily Health Policy Report
Nov 02, 2009

The New York Times: “More and more, the Great Health Care Debate of 2009 is a numbers game. And the longer the debate goes on, the squishier the numbers seem to get. For months, many leading Democrats, including President Obama, have pushed for the creation of a government-run insurance plan to compete with private insurers. A main argument was that a public plan would save people money. It would not be under pressure to earn profits, pay high private-sector salaries or deny needed care.” After the release last Thursday of the House Democratic leaders’ health care bill, the Congressional Budget Office said “the public plan would cost more than private plans and only six million people would sign up” (Herszenhorn, 11/1).

The Associated Press: Coverage numbers regarding the Democrats’ legislative push “for a government insurance plan to compete with private carriers are finally in: Two percent. That’s the estimated share of Americans younger than 65 who’d sign up for the public option plan.” That statistic “is raising questions about whether the government plan will be the iron-fisted competitor that private insurers warn will shut them down or a niche operator that becomes a haven for patients with health insurance horror stories.” The CBO also said the plan would likely attract a “less healthy pool of enrollees” and would likely have premiums higher than the average for private plans (Alonso-Zaldivar, 11/1).

Kaiser Health News: The actual figure estimated to enroll in the public option would be about six million. “And that number could shrink because states may decide to opt out of a public insurance plan, an escape clause that’s likely to be included in the Senate plan. … The CBO reasoned that the plan may not be able to offer a price advantage — in part because the House bill requires a government-backed insurer to negotiate payment rates rather than dictate them to hospitals and doctors… If the number of people in the public plan turns out to be six million in 2019, that would work out to an average of 120,000 per state. But that number probably would be smaller in the smallest states, perhaps totaling just tens of thousands.”

“Predicting the states’ responses is tricky, even where Republicans and conservative Democrats predominate. Some say the consumer appeal of a public plan could trump criticism that government plans would eventually drive out competition and lead to the federalization of health care” (Pianin, Carey and Appleby, 11/1).

The Wall Street Journal reports that costs could be driven up in the public option because of increased utilization of services by public option enrollees and that the “payment rates the government negotiates with health-care providers would, on average, be comparable to those paid by private insurers, eliminating a cost-saving advantage many Democrats aimed to give the plan. The CBO says its findings aren’t conclusive” (Adamy, 10/31).

Remember Medicare for All in the healthcare reform debate

By Kay Tillow
Coordinator, All Unions Committee For Single Payer Health Care–HR 676, Nurses Professional Organization
The Hill
11/03/09

We are in danger of losing the opportunity to bring Improved Medicare for All, a single payer plan, before the Congress. Last July Congressman Anthony Weiner and six of his colleagues on the Energy and Commerce Committee attempted to substitute the real public option–HR 676, a single payer plan–for the healthcare reform in the House. Speaker Nancy Pelosi assured them that if they withdrew the amendment in committee they would have an opportunity to bring it to the House floor for a debate and vote. Now Pelosi is threatening to keep the Weiner Single Payer Amendment from seeing the light of day.

If we were able to get this plan really on the table and before the nation in a meaningful way, we could win this hands down. Even Blue Dog Mike Ross, in an unguarded moment, asked why not just have Medicare for All. HR 676, the national single payer legislation introduced by Congressman John Conyers, would cover everyone for all medically necessary care through an Expanded and Improved Medicare for All. The bill and its advocates have been blocked, excluded, and beaten back in the current national healthcare reform debate.

Yet Medicare for All continues to raise its head. When single payer advocates were excluded from the White House kick off meeting for health care reform, doctors’ opened the door to two single payer advocates with a plan to protest at the White House gate. When Senate Finance Chair Baucus ruled single payer off the table, thirteen doctors, nurses, and others rose to protest. Baucus had them arrested. Those gutsy advocates pried open another door and won a round of publicity for single payer. But still not a place at the table.

Yet support for single payer continues to grow. Its simplicity, humanity, and economic efficiency win more supporters each day. The Kentucky House of Representatives, four other state legislative bodies, scores of cities and counties, a half dozen giant religious denominations, NOW, the NAACP, and the National Conference of Mayors have called for passage of HR 676. For unions, it’s the plan of choice. At each contract deadline the double digit rise in health care costs gobbles up the lion’s share of bargaining power. For that reason, 578 unions including 39 state AFL-CIO’s and 134 central labor councils have endorsed HR 676. In September the national AFL-CIO Convention declared unanimous support for single payer as the social insurance plan necessary to achieve social justice.

When Physicians for a National Health Program founder Quentin Young, testified before a House committee last June, Representative Weiner listened and was impressed. Weiner turned HR 676 into an amendment that would transform the House bill into a single payer plan. He popularized it as Medicare for All and catapulted the discussion into the national media with his feisty good humor and popular style.

Now Pelosi wants to renege on her promise to Weiner. We have sent an action alert to over 19,000 unionists asking them to contact Pelosi, and Waxman (who relayed Pelosi’s commitment publicly) and Slaughter (who heads the rules committee) to assure that they allow the Weiner amendment to come to the floor.

The “public option” that remains in both the Senate and the House bills is pitiful and powerless–totally incapable of providing cost control. Those bills, with their forced mandates and fines, their massive transfer of public funds to the insurance industry, and their ban on bulk buying power to rein in the pharmaceutical companies, will fail woefully to cover our people and to make that care affordable.

Pelosi should stick to her promise. We’ll keep up the effort to make her do so. Either now or later Medicare for All will have to come to the table. We’ll keep building the movement to make that happen.

My Kind of Medicine: Real Lives of Practicing Internists: Andy Coates, MD

By Catherine Nessa
American College of Physicians Medical Student Newsletter
October 2009

On any given weekend during the fall of 2004, Andy Coates was never where you might expect–he wasn’t at home with his children or outside working in the yard. He wasn’t at a restaurant having dinner with his wife or at the ballgame with his buddies. He wasn’t at a party thrown by neighbors or friends, or even on a beach chair on vacation. Instead, Andy Coates spent his weekends at Columbia Memorial Hospital in Hudson, NY, with the barest of accommodations: meals were brought in by cooler, his bed was a cot in a room in a recently-closed nursing home across the street from the hospital, and for entertainment, he had his work. For many physicians such an arrangement might be unappealing, but it was perfect for Dr. Coates, who has found satisfaction and fulfillment in unexpected places by taking roads less traveled.

The Late Bloomer

The weekend shift in Hudson was Dr. Coates’ idea. As he explains, he wanted to work in an underserved rural community, and sought a situation which would allow time to study and advocate for Physicians for a National Health Program. He proposed that he work on weekends and actually live at the hospital from Friday to Sunday. He loved it. “To be able to dash across the street to the ICU to help stabilize a patient at 2:00 a.m. on a Sunday? What a marvelous experience, to help save someone’s life!” he says. He soon earned a reputation for consistency during the four-month job. On one occasion, he was called to the ER by nurses for his opinion on another physician’s patient. The nurses felt the treatment ordered would harm the patient, and they were hesitant to question the doctor. “What could I do? I wondered,” Dr. Coates recalls. “I just went over and talked with the physician and asked how things were going. We talked about the case and it was clear that the nurses were correct. I said I thought I’d seen similar patients in the past, with words to the effect that isn’t it amazing that conservative measures would usually work for the problem he had identified. And then I watched as he reached down and crossed out his orders. He never knew that the nurses put me up to it. I remember the moment well. The doctor was struggling, but I could see that he was sincerely trying to help the patient.”

During those long weekends, the 47-year-old from upstate New York had proven himself to be a natural, but Dr. Coates was many things before he was an internist. Although he hoped to become a physician by the time of high school, he was drawn in other directions once arriving at college at the University at Albany. He pursued art, music, literature and history and eventually graduated with a degree in American History. When he married in his late 20s, he put medical school on hold and found work as a carpenter. “It was a choice,” he says. “I wanted to work with my hands as well as my brain.” He also during this time earned a masters degree in American History and gained acceptance to PhD programs at a number of prominent schools. Finally, at the age of 32, he decided it was time to return to his original ambition, and enrolled in medical school at Columbia University in New York City. Internship, residency and chief residency at Bassett Healthcare in Cooperstown, NY, followed, and at long last, Andy Coates was a doctor.

The Shepherd

At his first job following residency, as a hospitalist at St. Peter’s Hospital in Albany, NY, Dr. Coates began to develop a unique perspective on what it meant to be a physician. “I was then the only full-time hospitalist for a multi-specialty group, and I came to understand and see the hospital itself as a living social organism,” he says. “I saw my role in it, and felt it was my responsibility to shepherd the patient through the hospital.” He explains how he would arrange to be notified exactly when a patient’s results came back from radiology or pathology, so he could meet with the patient immediately to talk about it. “I would guide them through the hospitalization. It was enormously rewarding,” he says. He also began caring for many patients at the end of their life, and took to it well, finding poignant meaning in the difficult role.

The weekend hospitalist position in Hudson was his second job; for his third he made another unusual choice, taking a brief assignment as an internist at the Northern Navajo Medical Center in Shiprock, New Mexico. The hospital was a teaching site for his medical school and had an excellent reputation. He says it was the best thing he could have done in many ways. He developed a profound respect for the Navajo culture, and is convinced the experience made him a better physician. “A large percentage of my patients spoke Navajo, not English, and one of the nurses would translate,” he says. “I gained confidence among the Navajo because I learned that I was able to practice medicine effectively outside of my own culture.”

Dr. Coates returned to Albany in 2005, taking a job as a hospitalist at St. Peter’s. He had by that time earned a specialty in hospice and palliative medicine, which he would put to use the following year, when he began working predominantly as a palliative medicine physician. He was gripped by the issues presented by life-threatening illness. “When you are caring for people who face their own end, there are so many more things that should go along with that,” he says, “dignity, difficult decision-making, family meetings–all of that was compelling to me and I was proud to try to help the patients and their families.” He began to augment his palliative medicine practice with outpatient work with patients with severe disabilities, including mental illness. It prepared him for his next roles as director of medical services at Capital District Psychiatric Center and faculty member at Albany Medical College, as assistant professor of medicine and psychiatry, where he has been since early 2007.

Finding His Niche

In these roles, he seems to have come into his own. “Teaching third year medical students and helping with the psychiatric residency–I’ve been very proud of that,” he says. “Teaching the students is absolutely the most inspiring hour of the week. I love to hear my students’ reflections and insight. It’s such a poignant time for them. They’re entering a new world–from here on out they’ll be physicians. Teaching is without a doubt the highlight of my professional life.”

Dr. Coates says his choice to pursue internal medicine has allowed him the opportunity to pursue things he would never have considered otherwise. He loves it all. “The amazing thing is that there has been a convergence of interests and abilities in my career,” he says. “The professional rewards of being an internist have been fascinating and unexpected, ultimately both empowering and so very humbling.” In his work, he believes he has found the perfect outlets for his abilities and interests. “I am most comfortable when patients are on the margins of human experience,” he says. “If I can make a difference, that’s my goal. And as an internist there are many, many ways I have been able to do that.”

One recent patient in particular embodied much of this for Dr. Coates. “She was severely mentally ill and had lung cancer but was adamant in her belief that treatments for the cancer would be worse than the cancer itself,” he explains. “So we went through the process with her and with her family, and convened an ethics committee and a palliative care team. And what meant a lot to me was that we were able to stick up for her, carefully, to defend her autonomy. Working with her family and the psychiatric team was a remarkable experience.” Eventually Dr. Coates and his team were successful getting the patient discharged from the institution, after which he continued to serve as her physician. “She made absolute peace with her life, courageously,” he recalls. “I’m so proud to have been a part of that.”

Dr. Coates doesn’t indulge in a lot of leisurely activity, but he does value his time with his wife of 19 years, Lori, and their three children, Noah, Harriet and Evelyn. One of the benefits of his career he says is the fact that it gives him flexibility, which has allowed him the time when he needs it most, which seems now to be more than ever. True to character, he is pursuing new interests. His volunteer advocacy work for Physicians for a National Health Program led to a spot on the organization’s national board of directors and an ongoing schedule of public speaking engagements. Most recently, he has spoken in a series of community meetings in towns across New York’s rural Delaware County, at sessions of professional societies, in an interview by the BBC, and at the annual meeting of the International Association of Health Policy in Madrid, Spain. In between he does commentaries on his local public radio station, tends a blog, and leads a statewide grassroots coalition, Single Payer New York. He views the effort for national health insurance as his “chance to make a difference for all patients.” Through the years, Dr. Coates has aimed his arrow at many targets–from art to history to carpentry to hospital medicine to psychiatry to palliative care–but he always seems to hit his mark, and finds fulfillment in places that are uncomfortable for most. He will likely do well in his new ventures as he has in others, and will without a doubt bring something different to them while he’s at it–a combination of intangible and atypical qualities and experiences that can come only from Andy Coates.

Health Care Abroad: Taiwan

By Anne Underwood
New York Times
Prescriptions blog
Nov. 3, 2009

William Hsiao is a professor of economics at the Harvard School of Public Health and co-author of the 2004 book “Getting Health Reform Right.” He served as a health care adviser to the Taiwan government in the 1990s, when officials decided to reform that country’s health care system and to introduce universal coverage. He spoke with Anne Underwood, a freelance writer.

Q. Taiwan instituted universal insurance in 1995. What was the health care system like before?

A. Only a portion of the people were insured, including civil servants, employees of large firms and farmers. The military had its own system of coverage. But 45 percent of the population did not have insurance, and they faced financial barriers to access to health care. President Lee Teng-hui felt strongly that he wanted to do something concrete and visible for all the citizens. He thought of introducing national health insurance to touch the lives of all the people. There was a sense in Taiwan that health care is needed by everyone and a country has to assure everyone equal access.

Q. How did you become involved in the health care reform process?

A. The government initially appointed four Taiwanese professors to lead a task force of technical experts. But the four professors all had different ideas. It was like a wagon drawn by four horses, with each going in a different direction and nobody driving. After a year of this, government officials realized there was a problem. In addition, they wanted someone who understood health systems and health care abroad and what lessons other countries could offer to Taiwan. The domestic experts did not have much international experience.

I was invited to a three-day workshop, where they tested me. At the end, I was put in charge of the task force of four professors and 16 other technical experts. It turned out to be a big advantage that I’m not Taiwanese and had no aspirations of getting a job in Taiwan. At the end of the day, our recommendations and findings were perceived as more objective and free of self-interest.

Q. What was your assignment as head of this task force?

A. We had to design a national health insurance plan for Taiwan, based on international experience. Government officials wanted to understand how other advanced countries fund and organize health care and learn from their successes and failures, so I made a study of the systems in six high-income countries — the United States, the U.K., Germany, France, Canada, Singapore and Japan.

Q. And what was your conclusion at the end of this study?

A. We adopted a single-payer system along the Canadian lines. I did not invent it. I’m just in the transfer-of-knowledge business.

Q. Why did you choose the Canadian model?

A. Canada has a single-payer system with universal insurance coverage. It offers people free choice of doctors and hospitals, and it has competition on the delivery side between public and private hospitals. The quality of health services is very high, and people were very satisfied with the system from the 1980s through the mid-1990s.

Unfortunately, in the early-to-mid 1990s, Canada went through a severe recession for four or five years. The budget became very tight. The government underfunded national health insurance, which led to long waiting lines for elective surgery, MRIs and so forth. But when Canada adequately financed its N.H.I., it was a very good system.

Q. In Taiwan, can people choose any doctor or hospital they want?

A. Yes, any provider. Americans talk about choice. But in fact, insurance plans in this country restrict what providers you can go to. Canada gives its citizens more choice of providers. So does Germany. So does England. So does Taiwan.

Q. How comprehensive is the coverage?

A. It covers prevention, primary care and hospitalization, among other things.

Q. I’ve read that it also covers Chinese massage, acupuncture, traditional herbal medicine, mental health care, dental, vision and long-term care.

A. Yes, these services are covered. We tried to design a benefit package that would give people what they value. For many Taiwanese, that includes traditional Chinese medicine. Though Chinese medicine is not 100 percent proven to be medically effective, people believe in it. And some therapies have been proven effective. For example, when acupuncture is given in certain spots, it stimulates the brain to release opiates.

Q. The Taiwanese system also covers home care.

A. You need home care by visiting nurses for people who are chronically ill or bedridden. It’s not rocket science to recognize this. Some people argue that the patients should pay for home care themselves. But if people have to pay out of pocket, they might not ask for visiting nurse services and their illnesses may get much worse. Then they will need to be hospitalized.

Q. Is the system very expensive?

A. Expensive is a relative term. Taiwan spends 6 percent of G.D.P. on health care, compared to 16 percent in the United States.

Q. How much do people have to pay?

A. If you’re employed, your employer pays 60 percent of your premium. The employee pays 30 percent, and the government subsidizes 10 percent. The government fully subsidizes the premiums for the poor and gives partial subsidies to veterans, the self-employed and farmers.

Q. How much is the typical premium?

A. The total insurance premium for employed workers is 4.6 percent of wages. That’s much lower than in the United States, where the average is between 12 and 20 percent of wages for those who are covered by their employers.

Q. Are there co-pays, too?

A. Yes. The task force felt that service should not be totally free or else people might waste services. For example, we studied what happened in Taiwan when some insurance policies gave prescription drugs free to everyone. One-third of the drugs dispensed were never taken but thrown away. You can imagine, if you have free office visits, some people will say, “I have this little ache. I’ll go see the doctor because it’s free.” We wanted to moderate this waste.

Q. How high are co-pays?

A. The charge is $2 for a visit to a clinic and about $4 to a hospital outpatient department. The co-pay for hospitalization is now 10 percent for the first 30 days and 20 percent for the days beyond 30 days. For prescriptions, it’s 20 percent of the cost of the drug, but capped at $6 for each prescription. Taiwan also sets a ceiling on the total co-pays, so patients won’t face bankruptcy.

Q. How long did it take to implement this program?

A. Less than a year. Mr. Lee pushed through the legislation in four to five months, because an election was coming. Then he asked for the new system to be implemented six months after that — and they did it.

Q. What percent of the population is now insured?

A. Within the first year, Taiwan managed to insure 95 percent of the population. That increased that by another percent or so each year, until they reached 98 percent. They had trouble with that last 2 percent, because some were living overseas and others were homeless. The government literally sent people to find the homeless under bridges and enroll them. Now they have close to 99 percent enrollment.

Q. Has this translated into better life expectancy or lower complication rates from major diseases?

A. There is evidence of positive health results for select diseases, like cardiovascular disease and kidney failure. But overall, it’s really difficult to say that national health insurance has improved the aggregate health status, because mortality and life expectancy are crude measurements, not precise enough to pick up the impact of more health care. That said, life expectancy is improving, and mortality is dropping. And everyone now has access to good health care.

Q. What does the system do particularly well?

A. In addition to covering everyone, it has a uniform system of electronic health records. Every patient has a Smart Card. When you go in for services, the physician puts the card into his computer. You give him the code to access your records, which are all stored on the card — what medications you’ve taken, what tests, along with the results, the last time you saw another physician. With a single, unified electronic system, it improves treatment and it also vastly reduces claims processing. Hospitals and doctors get paid in a week or two. It’s a paperless system. That’s why it keeps administrative costs down to 2.3 percent of the total premium. In the United States, it’s more than 10 percent.

Taiwan was also able to control health-expenditure increases very well in the early years. Unfortunately, now that the government budget is tight, it is overdoing it.

Q. What are the system’s weaknesses?

A. In the legislative process, compromises had to be made. First, the president yielded on payment reform, so Taiwan kept its fee-for-service payment system. Unfortunately, that encourages doctors and hospitals to give more treatment in order to boost their income.

Second, the Taiwanese system doesn’t have a systematic way to monitor and improve quality of care.

Third, in the legislative process, they rejected a provision to adjust the premium automatically when the national health system depletes its reserves. In every country, health care costs are increasing faster than wages. When that happens, the premium has to go up. But that provision wasn’t incorporated into the law. As a result, the system is running a deficit. National health insurance tries to cut the fees for hospital and physician services. But eventually these fee reductions will adversely affect the quality of health care.

Q. What’s the most important lesson that Americans can learn from the Taiwanese example?

A. You can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.

http://prescriptions.blogs.nytimes.com/2009/11/03/health-care-abroad-taiwan/

Drew Altman on Americans affording health care

Interviews with Washington's power players

Drew Altman, President and CEO of the Henry J. Kaiser Family Foundation
The Washington Post
November 2, 2009

MS. ROMANO: In your view, what must a bill have in order to be a step forward in health care reform.

MR. ALTMAN: Well, you know, we’re having this debate because the American people, average working Americans, became really worried about and are having real problems just paying their health care bills, and that’s having a real impact also on their family budgets and their ability to pay for other things, pay their rent and mortgage or put a kid through college.

We’ve forgotten a little bit that that’s where this came from. That’s why health got traction again as a political issue.

So the main thing I actually want to see–us health care people tend to talk about this in terms of health care goals, access to care and the quality of care. The first thing I look for is, is this legislation actually responsible–responsive in a meaningful way to the meat-and-potatoes pocketbook problems that average Americans are having, paying for their health care which brought us this debate in the first place. That’s number one for me.

*****

MS. ROMANO: With President Obama trying to cap the cost of these plans at $900 billion over ten years, does that make the discussion about subsidies very important?

MR. ALTMAN: It is a really important discussion, and one of the things that’s happened is, as so much of the debate lately has focused on this hot-button issue [of] the public option. Flying under the radar screen and not getting as much attention are these bread-and-butter consumer issues about will the policies be affordable for people who now have to buy health insurance coverage, are the subsidies high enough, is the coverage that people are going to get going to be adequate.

And I think, as we get to two bills and then one bill that the country can really focus on and that people in the media can really focus on, that issue of the affordability of the coverage will rise to the surface and will become a really big issue.

*****

MR. ALTMAN: I think the public option issue has diverted attention from lots of other issues, and I think this issue of affordability will emerge as a big issue. And there’s a tradeoff as they design this legislation between keeping the overall sticker shock, the price tag of the legislation down and the generosity of the subsidies they can give to people and the comprehensiveness of the coverage that people get, how high–how big those deductibles will be that average middle-class families are going to be asked to pay.

And that’s a very big issue. It’s going to be a big issue not just for the people who are in these exchanges, who get these policies, but for the American people generally who look at this and say is this a fair deal, is this a good deal for people who now have to have health insurance coverage.

I think this is the sleeper issue still. This affordability issue.

And it’s hard to understand. They’re focused on the public option. They haven’t gotten to it yet. So this issue of affordability, I think, is a sleeper issue because it’s complicated, hard to understand how coverage works, what an actuarial value is, how the subsidies work at different income levels, and because they’re focused on the public option. Everyone is so focused on the public option right now, but I think as they get to one bill that everyone can put under a microscope, then this issue of the subsidies and the coverage will really rise to the surface, and we’ll have a much bigger debate about that.

And that’s the consumer issue. It’s the real meat-and-potatoes consumer issue in this legislation.

*****

MS. Romano: Is there a way to hold private insurers accountable on costs other than a government option?

MR. ALTMAN: Well, you know, there are comprehensive reforms of the insurance industry in the legislation, but the one thing they didn’t do in this legislation which was proposed in the Clinton health reform plan, which as we all know failed, they did not propose this time around caps on the increases in insurance premiums. They didn’t say, “Your premiums can only go up two times inflation in the general economy.” That–those–that kind of price controls or regulation, they just didn’t think that would work this time, or they didn’t think it would fly. Anyway, it’s not in the legislation this time.

So, no, there aren’t–I mean, one of the characteristics of the legislation this time is there are not strong controls over the increases that can occur in premiums in the future.

*****

MS. ROMANO: Health care costs are a huge burden on American businesses. Are there enough incentives in these different legislations to help the businessmen pay for this, pay for it for employees, or are we fast approaching a point where businesses will be no longer offering health insurance to employees?

MR. ALTMAN: Well, it’s a big problem in this. The reason we’ve seen a sort of slow drip-drip-drip of coverage out of the employment-based health care system is simply that business can’t pay the cost any longer.

I did a projection the other day that showed that if current trends continue, in 20 years the average cost of a family premium could be 30,000 bucks a year. So we’re not on a good trajectory.

MS. ROMANO: Wow!

*****

MS. ROMANO: Do you see a time when the U.S. will ever drift towards a single-payer system?

MR. ALTMAN: You know, I don’t know for sure, but I certainly think it will be a long time, and I know the single-payer people, you know, don’t like to hear that because they believe so strongly in that approach, but we’re at a point in time now when the approach is favored by the two wings, an all-market approach–people get a voucher, and they shop for themselves–and a single-payer approach are not in the cards.

And so what we’re really looking at, if you view it through that lens, is we’re looking at some form of a centrist deal that brings together elements that the right likes and that the left likes and builds on the existing system. It’s a little bit messy, but that’s all that can fly right now in our political system.

*****

MS. ROMANO: Is the U.S. obligated to provide every citizen with health insurance–health care–let me ask that again. Is the United States obligated to provide health care to all of its citizens?

MR. ALTMAN: The way I would answer that question is to say that it is certainly something that we should do. And I don’t know anybody–you know, right, left, or center–who doesn’t believe that at some level. The debate is about how we get there, and, unfortunately, that debate about how we get there has been a really bitter and difficult debate in our country. And the tough part of it is, if you scratch beneath the surface and look at the difficult part of it, it is fundamentally about redistributing wealth in our country; that, ultimately, it means, as some of us who have more, have to pay, you know, a little bit more, so that others who have less can have health care. You can slice it and dice it a million ways with this kind of tax or that kind of mandate, but, at the end of the day, that’s what’s involved, and we don’t do that too easily in our country, too happily, or too willingly.

http://www.washingtonpost.com/wp-dyn/content/article/2009/11/02/AR2009110201285.html

Comment:

By Don McCanne, MD

Drew Altman is a very intelligent and very well informed advocate of a health care system that works well for all of us. His only handicap is that, as President and CEO of the Henry J. Kaiser Family Foundation, he must maintain his reputation as a highly credible but impartial voice on health care reform. That requires diligently negotiating his way through the minefield of Washington politics.

Setting ideology and politics aside, Altman makes it clear that wealth redistribution is absolutely essential if everyone is going to have the health care that they need. By far the simplest, most efficient, and most equitable method of doing that would be to enact a single payer system. But this is where ideology and politics enter.

How do you meld the ideology of single payer with the ideology of consumers shopping in a market of private health plans? After all, there’s that redistribution problem. The solution currently being advanced is to perpetuate the market of private health plans while superimposing government policies to achieve redistribution of wealth, without which it would be impossible to finance care for everyone.

The combination of private health plans and government policies requires a complex, difficult balancing act. Some of the variables that must be brought into balance include the package of benefits to be covered by the plans, the premiums to be charged for the plans, annual premium increases not limited by regulation, actuarial values of the plans, eligibility for the insurance exchanges, the value of the vouchers used to purchase the plans, the eligibility for the vouchers as related to income or as to wealth as some suggest, the size of the deductibles, copayments and coinsurance, financial support for out-of-pocket expenses, caps on yearly or life-time spending, payment for non-covered or out-of-network products and services, the variable contribution rates for employers, caps on federal and state budgets that limit the level of government funding, extensive corrections in the Medicare program, eligibility for and financing of taxpayer-financed Medicaid programs, financing the complex administrative services for a program in constant flux because of ever-changing eligibility status and contribution levels, balancing income taxes, payroll taxes, possibly VAT taxes, payroll deductions, taxes on health care products, taxes on insurance plans… (continue with your own additions to this list).

Once you have the full list, just try changing any variable and see what happens to the rest of the variables. What will be the most shocking is to observe what happens to middle-income Americans. They will be clobbered by health care costs!

The primary reason for these complex adjustments is that health care is now so expensive that redistribution is essential if everyone is to have the care they need. The private insurance market by itself is totally incapable engineering redistribution. Drew Altman says that this would be “a little bit messy,” and that, at the end of the day, we won’t do it “too easily, too happily, or too willingly.” But that’s as far as Drew Altman’s job description will allow him to go.

We are not so constrained. Soon we will have “one bill that the country can really focus on and that people in the media can really focus on; that issue of the affordability of the coverage will rise to the surface.”

We can take Drew Altman’s astute observations on “the meat-and-potatoes pocketbook problems that average Americans are having in paying for their health care,” and we can run with it. We know how to fix it, even if he can’t publicly endorse our model of an improved Medicare for all. When we succeed, Drew Altman certainly will be at least a little bit smug. Let’s go!

Expanding Medicaid to save money

Changing Numbers Make Meaning Even More Elusive

By David M. Herszenhorn
The New York Times
November 1, 2009
Once Ms. Pelosi realized that she could not get a robust public option, she needed another way to reduce the bill’s cost. The answer was a wider expansion of Medicaid, the state-federal insurance for the poor.
In just one of the counterintuitive concepts in the health care debate, enrolling more people in Medicaid saves money because it is cheaper than subsidizing private insurance, and because states share the cost.
The House bill would increase total Medicaid costs for states by $34 billion. States, of course, object to such added expenses.
http://prescriptions.blogs.nytimes.com/2009/11/01/changing-numbers-make-meaning-even-more-elusive/

The version of the House health care reform bill released last week would further expand Medicaid eligibility to individuals with incomes up to 150 percent of the federal poverty level. This expansion was prompted by the self-imposed requirement to avoid any deficit spending as a result of this legislation. It will cost the government less to enroll these individuals in Medicaid than it would cost to provide them with subsidies to purchase private health plans.
Some implications of this policy:
* Medicaid benefits are more comprehensive than private plans and cost sharing is negligible, unlike private plans. Medicaid patients have more care covered with much less in out-of-pocket costs.
* Taxpayers will be paying less to provide these individuals with Medicaid than they would have paid in subsidies to purchase private plans. Private plans are more expensive even though they provide less coverage.
* As a welfare program, representing a population without an audible political voice, Medicaid is chronically underfunded.
* Inadequate reimbursement rates due to inadequate funds results in a lack of willing providers. Too many physicians are not willing to accept the losses under this program. This lack of providers impairs access to care.
* Many states are struggling with budgets burdened by massive Medicaid spending. Although this expansion would use federal funds initially, some of the financing burden would be shifted to the states even though they do not have the budget flexibility of the federal government.
On paper, Medicaid looks like a great program. It provides a generous benefit package for lower-income individuals who cannot afford to purchase private health plans. In reality, most Medicaid patients do not have the same access to essential specialized services that wealthier privately insured individuals do, and access to even basic services is often compromised.
Expanding the Medicaid program further locks in a tiered health care system, effectively providing less for the least amongst us. In health care, that’s simply not acceptable.

Expanding Medicaid to save money

Changing Numbers Make Meaning Even More Elusive

By David M. Herszenhorn
The New York Times
November 1, 2009

Once Ms. Pelosi realized that she could not get a robust public option, she needed another way to reduce the bill’s cost. The answer was a wider expansion of Medicaid, the state-federal insurance for the poor.

In just one of the counterintuitive concepts in the health care debate, enrolling more people in Medicaid saves money because it is cheaper than subsidizing private insurance, and because states share the cost.

The House bill would increase total Medicaid costs for states by $34 billion. States, of course, object to such added expenses.

http://prescriptions.blogs.nytimes.com/2009/11/01/changing-numbers-make-meaning-even-more-elusive/

Comment:

By Don McCanne, MD

The version of the House health care reform bill released last week would further expand Medicaid eligibility to individuals with incomes up to 150 percent of the federal poverty level. This expansion was prompted by the self-imposed requirement to avoid any deficit spending as a result of this legislation. It will cost the government less to enroll these individuals in Medicaid than it would cost to provide them with subsidies to purchase private health plans.

Some implications of this policy:

* Medicaid benefits are more comprehensive than private plans and cost sharing is negligible, unlike private plans. Medicaid patients have more care covered with much less in out-of-pocket costs.

* Taxpayers will be paying less to provide these individuals with Medicaid than they would have paid in subsidies to purchase private plans. Private plans are more expensive even though they provide less coverage.

* As a welfare program, representing a population without an audible political voice, Medicaid is chronically underfunded.

* Inadequate reimbursement rates due to inadequate funds results in a lack of willing providers. Too many physicians are not willing to accept the losses under this program. This lack of providers impairs access to care.

* Many states are struggling with budgets burdened by massive Medicaid spending. Although this expansion would use federal funds initially, some of the financing burden would be shifted to the states even though they do not have the budget flexibility of the federal government.

On paper, Medicaid looks like a great program. It provides a generous benefit package for lower-income individuals who cannot afford to purchase private health plans. In reality, most Medicaid patients do not have the same access to essential specialized services that wealthier privately insured individuals do, and access to even basic services is often compromised.

Expanding the Medicaid program further locks in a tiered health care system, effectively providing less for the least amongst us. In health care, that’s simply not acceptable.

CBO report on the public option

Preliminary Analysis of the Affordable Health Care for America Act

Congressional Budget Office
October 29, 2009
The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have completed a preliminary analysis of H.R. 3962, the Affordable Health Care for America Act, as introduced on October 29, 2009.
The options available in the insurance exchange would include private health insurance plans as well as a public plan that would be administered by the Secretary of Health and Human Services (HHS). The public plan would negotiate payment rates with all providers and suppliers of health care goods and services; providers would not be required to participate in the public plan in order to participate in Medicare. The public plan would have to charge premiums that covered its costs, including the costs of paying back start-up funding that the government would provide.
Roughly one-fifth of the people purchasing coverage through the exchanges would enroll in the public plan, meaning that total enrollment in that plan would be about 6 million.
That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges. The rates the public plan pays to providers would, on average, probably be comparable to the rates paid by private insurers participating in the exchanges. The public plan would have lower administrative costs than those private plans but would probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)
http://www.cbo.gov/ftpdocs/106xx/doc10688/hr3962Rangel.pdf

And…

Affordable Health Care for America Act

H.R. 3962 (replaces H.R. 3200)
Introduced October 29, 2009
SEC. 321. (b) (2) ENSURING A LEVEL PLAYING FIELD
Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost-sharing.
H.R. 3962 (1990 pages)
http://docs.house.gov/rules/health/111_ahcaa.pdf

What happened to that public option that the liberals promised us when they decided not to try to enact the golden standard of a single payer national health program? You know, that government program, like Medicare, designed to be less expensive, more efficient and more equitable, and that each of us could choose in place of private health plans. Really, what happened to it?
Well, Congress plowed it under. Their first priority never was about patients. It was always about taking care of the private insurance industry. Instead of enacting policies that would provide everyone with affordable health care, they have crafted reform that provides a robust insurance market, and then patients are crammed into whatever niches that market creates.
A prime example of their approach is that they have insisted that the public option be prohibited from using policies that provide the greater efficiency and effectiveness of government health care financing programs such as Medicare. To protect the private insurers from “unfair” competition from the government, they have included in the legislation policies to “ensure a level playing field.”
What does the CBO predict will be the outcome of these policies? The public option would have “premiums that are somewhat higher than the average premiums for the private plans in the exchanges,” and fewer than 2 percent of our nation will be enrolled in our own Medicare-like plan that was promised as a choice for all of us.
The golden standard? This public option is not even made of brass. It’s merely the slag cast off while the private insurers walk away with the ingots.
(NB: Do not assume that this message is a plea for a “robust” public option. Adding a robust option to our dysfunctional, fragmented system of health care financing would have very little impact in reducing the waste, inequities, and inefficiencies in our system. This message is a plea to dump the private insurers into the slag pit and use our taxpayer ingots to purchase our own improved Medicare-for-all system.)

Four Arrested at Baltimore Health Insurance Protest

By SHARMINA MANANDHAR
Southern Maryland Online
Oct. 29, 2009

BALTIMORE (Oct. 29, 2009) – Four protesters, including two doctors, were arrested at a “single-payer health care plan” sit-in at the CareFirst insurance company office in Baltimore Thursday.

The protest, part of the “Patients Not Profits” campaign of the Mobilization for Health Care for All, was jointly organized by advocacy groups Prosperity Agenda, Healthcare-NOW!, and the Center for the Working Poor.

Baltimore was one of 20 cities nationwide to host such protests this week, said Kai Newkirk, national coordinator for the Mobilization in a conference call Tuesday.

Charles Loubert of Baltimore, Dr. Eric Naumburg of Columbia, Patricia Courtney of Millersville and Dr. Margaret Flowers were among about 30 protesters chanting “Single Payer Now, Health Care for All” outside the locked front doors of the insurance company office.

The protesters later entered the building through the back door, where the Baltimore City Police asked them to leave.

Loubert, Naumburg, Courtney and Flowers refused.

They were “completely cooperative” and were taken to the central booking facility in Baltimore where they are awaiting charges for trespassing, according to Anthony Guglielmi, Baltimore City Police spokesman.

CareFirst could not be reached for a comment.

The primary objective of the sit-in was to get insurance companies to stop denying health care, according to Kevin Zeese, executive director of Prosperity Agenda as well as a peace and drug policy reform activist who ran for the U.S. Senate seat in 2006 as a Green Party nominee.

Earlier, a delegation consisting of Zeese, Flowers, Naumburg and Maryland State Delegate Jill Carter, D-Baltimore, met with company representatives, demanding an end to “insurance abuse” and “immediate approval of all doctor-recommended treatments.”

“The basic response was, ‘Send it in writing, we’ll consider it,'” Zeese said. “They wouldn’t give us a response today.”

After the meeting, Carter said she was committed to introducing legislation to require CareFirst to disclose insurance denials.

“The issue isn’t just CareFirst, it’s the influence they have over elected officials, over politicians,” Carter said. “You know what? That’s not all CareFirst’s fault because politicians need to have some independence and not be swayed by just the money…”

Doctors spend more time fighting health insurance companies, causing a decline in their ability to provide quality health care, according to Flowers, a pediatrician and congressional fellow for Maryland Physicians for a National Health Program.

Flowers left her practice to work on health care reform full time, she said.

“When patients and doctors make a decision about what’s best for the patient, it’s very common for the insurance companies then to make you go through extra steps to get the tests, to get the medications that you need,” Flowers said before the arrest.

The current health care reform discussion has included the insurance and pharmaceutical company lobbyists, instead of “people who are giving care and receiving care,” Flowers said.

“They are the ones who know best about what reform we need,” Flowers said.

Before his arrest, Loubert said his 56-year-old son and daughter-in-law do not have health insurance because they cannot afford it.

“It’s a travesty in a rich country like ours that people have to go without health care,” said 81-year-old Loubert. “It’s a right and I argue with people about it … all of the countries that have single-payer-type systems are not socialized, they are democracy. They are developed countries and they have more sense than we do.”

http://somd.com/news/headlines/2009/10714.shtml

The Doctor Will See You

By Henry S. Kahn, MD
Atlanta, GA
Ad Libitum
Annals of Internal Medicine
Volume 15,1 Number 8

No knock. Needed
Perhaps a chance to talk
With the doctor
Would be nice.

Come to my fantasy
Office has no lock
Or guard
Or cashier
Or bars on the window.

Or door. Just a doorway
To find a seat
To catch your breath
To collect your thoughts
To ponder your pain.

We talk and then
We let some tears flow
And smile a bit.

No fee. Never
We speak of
Deductoauthorizeligibility.
Your wallet, if any,
Has not been lightened.
But you stand taller
And I feel richer.

UPDATE: Groundswell of sit-ins and civil disobedience at insurance company offices to demand real health care reform

From Mobilization for Health Care for All

* Supporters of health care for all have been occupying the lobby of a Louisville, Kentucky Humana insurance for over 24 hours (rally today at 11:30 AM outside the building)

* 119 arrests have occurred at actions in 19 cities at insurance company offices in the past month

* Rhode Island cancer patient who risked arrest Wednesday at UnitedHealth awaits answer about denial of claim for lifesaving bone marrow transplant

* Sit-in at 12 noon today in Philadelphia with 17 people risking arrest; One supporter intends to remain in police custody to inspire more civil disobedience * Three doctors arrested so far for health care for all, one in Los Angeles and two in Baltimore

WASHINGTON, DC — The Mobilization for Health Care for All continues to see a growing number of doctors participating in these actions. Yesterday Dr. Margaret Flowers, a pediatrician who has testified before Congress on the need for meaningful health care reform, was arrested in Baltimore and joined by Dr. Eric Naumberg, also a physician. Other physicians include Matt Hendrickson, MD MPH, who was arrested Wednesday in Los Angeles, and Dr. Ken Weinberg, who was present at a sit-in at Wellpoint insurance office in New York on Wednesday and has committed to risking arrest for health care for all in the coming weeks. 60 percent of doctors support aggressive health care reform, namely a universal health care system like Medicare for All, similar to what 37 other countries already have.

Acts of civil disobedience at insurance company offices are growing as people across the nation identify insurance companies as the real cause of the health care crisis, and see insurance company lobbying dollars in the way of health care reform. So far 119 arrests have occurred at actions in 19 cities at insurance company offices in the past month. In sit-ins and other acts of civil disobedience, people are demanding that insurance companies re-direct their lobbying funds to pay for doctor-requested treatments for people with life-threatening conditions. In some states, one in five of these requests is denied by insurance company bureaucrats.

LOUISVILLE, KENTUCKY — A group of seven health care for all supporters, including nurse Kay Tillow, have been occupying the lobby of Humana health insurance since 10 AM on Thursday, vowing to stay there to support a health care system that treats health care like a human right, and calling on insurance companies to step out of the way to make space for real health care reform. The “Louisville Seven” were joined by about 100 other supporters at a rally yesterday morning as they entered the building. They’re now entrenched in the building and will not leave the marble floor of Humana health insurance until their demands are met. The Louisville Seven will hold a demonstration with their supporters outside the building at 11:30 AM today outside the building.

PROVIDENCE, RI — Cancer patient Robert Darling, 59, resident of Warwick, Rhode Island, is awaiting a response from UnitedHealth about coverage of his lifesaving bone marrow transplant. Several years ago, Darling was denied the transplant by UnitedHealth even though his doctors stated that it was the only way to save his life. Darling called for months, eventually going to a hospital that would allow the transplant due to a federal government reimbursement plan. On Wednesday Debora Spana, a communications representative with UnitedHealth, said that she would find Darling’s file and get back to him, scheduling a meeting next week. The group also asked to meet with UnitedHealth CEO Stephen Hemsley. Research shows that Hemsley earns in income one out of every 700 dollars spent on health care in the US. Darling risked arrest yesterday when he entered the Warwick, Rhode Island, offices of UnitedHealth insurance company with other health care reform supporters and asked for answers regarding his denial of a lifesaving bone marrow transplant. The supporters occupied the lobby of UnitedHealth for over an hour, but Darling was willing to wait longer. He’s been waiting for five years for an answer from UnitedHealth.

PHILADELPHIA, PA — At least 17 people, mostly undergraduate students at Swarthmore College, will risk arrest at the Independence Blue Cross Blue Shield at 12 noon today at 1901 Market Street, Philadelphia, PA. Participants in the sit-in will demand that Blue Cross Blue Shield immediately approve all doctor-prescribed lifesaving care for their members and discontinue all campaign contributions and funding of anti-health reform lobby campaigns aimed at preserving the failed employment-based health care system. They will bring with them a letter for Blue Cross’s CEO, Joseph Frick, which he must sign immediately to promise that the company will meet these demands and he must promise to hold a press conference within a week to announce Blue Cross’s plans. The group will not leave until their demands are met or they are removed by police.

Judy Esber will be risking arrest with the rest of the group in Philadelphia. She will not give information to the police that would lead to her arrest until 100 more supporters of meaningful health care reform sign up to commit an act of civil disobedience. She hopes that her time spent in jail will inspire others to take action for a system that treats health care like a human right!

# # # More info: Mobilization for Health Care for All www.MobilizeForHealthCare.org

CBO report on the public option

Preliminary Analysis of the Affordable Health Care for America Act

Congressional Budget Office
October 29, 2009

The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have completed a preliminary analysis of H.R. 3962, the Affordable Health Care for America Act, as introduced on October 29, 2009.

The options available in the insurance exchange would include private health insurance plans as well as a public plan that would be administered by the Secretary of Health and Human Services (HHS). The public plan would negotiate payment rates with all providers and suppliers of health care goods and services; providers would not be required to participate in the public plan in order to participate in Medicare. The public plan would have to charge premiums that covered its costs, including the costs of paying back start-up funding that the government would provide.

Roughly one-fifth of the people purchasing coverage through the exchanges would enroll in the public plan, meaning that total enrollment in that plan would be about 6 million.

That estimate of enrollment reflects CBO’s assessment that a public plan paying negotiated rates would attract a broad network of providers but would typically have premiums that are somewhat higher than the average premiums for the private plans in the exchanges. The rates the public plan pays to providers would, on average, probably be comparable to the rates paid by private insurers participating in the exchanges. The public plan would have lower administrative costs than those private plans but would probably engage in less management of utilization by its enrollees and attract a less healthy pool of enrollees. (The effects of that “adverse selection” on the public plan’s premiums would be only partially offset by the “risk adjustment” procedures that would apply to all plans operating in the exchanges.)

http://www.cbo.gov/ftpdocs/106xx/doc10688/hr3962Rangel.pdf

And…

Affordable Health Care for America Act

H.R. 3962 (replaces H.R. 3200)
Introduced October 29, 2009

SEC. 321. (b) (2) ENSURING A LEVEL PLAYING FIELD

Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost-sharing.

H.R. 3962 (1990 pages)
http://docs.house.gov/rules/health/111_ahcaa.pdf

Comment:

By Don McCanne, MD

What happened to that public option that the liberals promised us when they decided not to try to enact the golden standard of a single payer national health program? You know, that government program, like Medicare, designed to be less expensive, more efficient and more equitable, and that each of us could choose in place of private health plans. Really, what happened to it?

Well, Congress plowed it under. Their first priority never was about patients. It was always about taking care of the private insurance industry. Instead of enacting policies that would provide everyone with affordable health care, they have crafted reform that provides a robust insurance market, and then patients are crammed into whatever niches that market creates.

A prime example of their approach is that they have insisted that the public option be prohibited from using policies that provide the greater efficiency and effectiveness of government health care financing programs such as Medicare. To protect the private insurers from “unfair” competition from the government, they have included in the legislation policies to “ensure a level playing field.”

What does the CBO predict will be the outcome of these policies? The public option would have “premiums that are somewhat higher than the average premiums for the private plans in the exchanges,” and fewer than 2 percent of our nation will be enrolled in our own Medicare-like plan that was promised as a choice for all of us.

The golden standard? This public option is not even made of brass. It’s merely the slag cast off while the private insurers walk away with the ingots.

(NB: Do not assume that this message is a plea for a “robust” public option. Adding a robust option to our dysfunctional, fragmented system of health care financing would have very little impact in reducing the waste, inequities, and inefficiencies in our system. This message is a plea to dump the private insurers into the slag pit and use our taxpayer ingots to purchase our own improved Medicare-for-all system.)