Speaker – Page 801

What about primary care?

“Uncomplicated” Primary Care?

By Josh Freeman
Medicine and Social Justice
October 8, 2009
I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.
However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position.
Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from (their Physicians Foundation report) they note:
“Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care.”
The American Academy of Family Physicians (AAFP) in its formal response to the Physicians Foundation report includes the following:
“This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as ‘anomalous’ and ‘simple frameworks’ without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”
Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care”. What is this “uncomplicated primary care” of which you speak?
The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult.
(Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He is author and editor of the Medicine and Social Justice blog.)
http://medicinesocialjustice.blogspot.com/2009/10/uncomplicated-primary-care.html

And…

Health Bills In Congress Won’t Fix Doctor Shortage

By Phil Galewitz
Kaiser Health News
October 12, 2009
Even as Congress moves to expand health insurance coverage to millions of Americans, it’s doing little to ensure there will be enough primary care doctors to meet the expected surge in demand for treatment, experts say.
The American Academy of Family Physicians predicts that the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine.
A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions — a 15 percent increase that would favor more primary care training — was considered dead on arrival because of its $10 billion price tag over a decade.
Instead, the House and Senate overhaul bills would redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies.
Proposals to significantly increase Medicare payments for primary care doctors have gone nowhere in part because the money would come from payments to higher-paid specialists — who, not surprisingly, oppose a pay cut.
Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said the extra training slots emanating from the redistribution of unfilled residency position would amount to a “drop in the bucket.”
http://www.kaiserhealthnews.org/Stories/2009/October/12/primary-care-doctor-shortage.aspx

The report by Dr. Cooper and his colleagues, cited by Dr. Freeman, was “A Report to the President and the Congress.” Since it was released only one month ago, this report likely did not influence the current legislation, but it is important because it does represent the cavalier views of all too many within and outside of the health care arena.
One of the promises of reform was to reinforce our primary care infrastructure. Although there are a few measures in the bill such as a nominal primary care bonus and a medical home pilot project, failure to train more primary care physicians will require many patients to rely on expensive care in our emergency rooms and expensive care through often inappropriate, direct self-referral to specialists.
We were promised that everyone would be covered and costs would be controlled. Neither will happen. And now the promise of providing primary care access to everyone will fall far short. Jiggling 1000 existing medical residencies just won’t do it.

Single-payer backers fight odds

More than 100 rally in Albany to try to revive plan, as vote by Congress expected this month

By BRIAN NEARING
Times Union (Albany, N.Y.)
Sunday, October 11, 2009

ALBANY — Since being diagnosed with chronic kidney disease six years ago, Stephanie Agurkis has not been able to get health insurance.

“I’m paying for treatments myself,” said the 29-year-old nursing student and part-time farm stand worker from Ithaca. “And every year that goes by, I am more and more in debt.”

Agurkis was among more 100 people who met Saturday at Albany Medical College to talk about the political campaign to bring a government-run national health care system to the United States.

In use in Canada and several other industrial democracies, such systems are called “single-payer” and one payer, the government, sets doctor and hospital fees, and pays all the bills, with patients charged nothing. Even though Democrats in Congress are currently crafting a health care reform plan to require people to buy private health insurance and keep insurance companies from excluding the unhealthy, backers of a single-payer plan think the idea isn’t dead yet.

The U.S. already has a single-payer system in Medicare, a health insurance program for the elderly. “We see this as Medicare for all,” said Andy Coates, a doctor at Albany Medical College and member of the advocacy group and conference sponsor Single Payer New York. “Necessary medical care is the responsibility of a modern democracy. The best way to share the cost is to have everybody in, nobody out.”

The fate of a single-payer plan in the Congress could be decided later this month, when a vote could come in the House on a proposal to embrace it, said U.S. Rep. Paul Tonko, D-Amsterdam, who sits on the Education and Labor Committee, one of three House committees that are trying to create a bill to pass.

At Saturday’s event, he said the chances of single-payer don’t appear bright.

“This summer, there were a lot of delaying tactics and denial syndrome during the debate on health care,” said Tonko, whose August public meeting on the issue drew an angry crowd that devolved into a shoutfest.

Asked about the upcoming vote on single-payer, Tonko said, “A lot of people are absolutely deaf to the issue, even within the majority (Democrats).”

Afterward, Coates said Tonko was being “practical and realistic,” and that health care reform is being blocked by the powerful health insurance lobby. “The industry is a very formidable opponent, that has millions and millions of dollars to spend on this.”

Single Payer New York Co-chairman Mark Dunlea said voters should ask their Congressional representatives to support the measure, which is sponsored by Rep. Anthony Weiner, D-Queens .

Dunlea said a single-payer plan would help pay for itself by cutting $400 billion in insurance company overhead and profits out of health-care costs.

To pay the for program, the measure proposes a 4.75 percent payroll tax, which would include the current 1.45 percent Medicare payroll tax. Further revenue would be raised by a 5 percent health tax on the top 5 percent of income earners, and a 10 percent tax on the top 1 percent of income earners.

Brian Nearing can be reached at 454-5094 or at bnearing@timesunion.com.

http://www.timesunion.com/AspStories/story.asp?storyID=851688

Is there any way out for Obama on health reform?

By Leonard Rodberg

Progressives worry that, if President Obama’s health reform plan (the “Plan”) fails to pass, a latter-day right-wing Gingrich movement will take over the Congress in 2010 and the White House in 2012. What I have not heard, but what I am increasingly coming to believe, is that if the Plan passes in any of its current forms, things will go just as badly for him. Why is that?

The general reason is that the Plan is a dog. It is a terrible, complex plan that will accomplish almost nothing. Relatively few people will benefit from it, while everyone who has to use health care will continue to experience the mess that is, and will continue to be, the American health care system. And, because of the new requirements built into the Plan, health care finance will become even more complex and confusing.

More specifically:

1. The large majority of people, who receive their insurance from their employer, will see no benefit whatsoever from the Plan. Most will, in fact, find their premiums rising as new requirements imposed by the Plan (e.g., the elimination of lifetime limits) raise the cost of insurance. And, of course, to their undoubted surprise, most of them will not have access to the public option, even if there is one.

2. Most provisions of the Plan will not become effective until 2013. This gives four years for Republicans to criticize the Plan, including (a) its use of cuts in Medicare reimbursements and Medicare Advantage premiums as principal sources of funding, (b) its lack of any real or believable mechanism for containing costs, and (c) its bureaucratic complexity.

3. The taxes on high-cost insurance plans, the other principal source of funding, will cause those who now have good insurance (called, pejoratively, “Cadillac” plans) to find these plans heavily taxed and their employers given a strong incentive to cut back on their benefits. Instead of reducing underinsurance, this part of the Plan will increase it. (And the rest of the plan does little about underinsurance at all.)

4. During the four years of waiting for the Plan to take effect, costs will continue to rise. By the time the Plan takes effect, costs are likely to be at least 25 percent greater than now. Even more people will find insurance and health care unaffordable. People will ask “What was health reform about?” The disillusionment will be great.

5. The complexity of the plan, including (a) federal rules regarding what kinds of employer-based insurance plans are “qualified,” (b) new income-tax forms that will be needed to implement the individual mandate, and (c) the process of determining income eligibility for everyone, will all lend themselves to criticism and even ridicule.

Is there a way out? Not, in my view, as long as Obama sticks with this worthless and unworkable Plan. Only if we were to adopt a much simpler plan that would benefit everyone — a Medicare for All plan — would he be seen as actually addressing the problem and really offering a workable solution. Short of that, he, and all of us, are in real trouble.

Leonard Rodberg is professor and chair of urban studies at Queens College, City University of New York, and research director of the N.Y. Metro Chapter of Physicians for a National Health Program (www.pnhp.org).

Nurses Blast Latest Price Gouging Threat by Insurance Giants, 'Massive Public Bailout Apparently Not Enough'

California Nurses Association/National Nurses Organizing Committee

For Immediate Release
October 12, 2009

Contact:
Charles Idelson, 415-559-8991 or 510-273-2246

The nation’s largest organization of registered nurses today condemned the latest campaign by the insurance industry, threatening massive increases in premium rates if it does not get its way on the healthcare bills currently before Congress.

America’s Health Insurance Plans (AHIP), the insurance industry trade lobby, Sunday released a report it commissioned, warning average family premiums will go up to $21,300 if the Senate Finance Committee bill is adopted.

“This is an outrageous threat by one of the richest industries in America,” said Rose Ann DeMoro, executive director of the 86,000-member California Nurses Association/National Nurses Organizing Committee.

“Our legislators should respond to this bullying and stop coddling a useless industry whose sole function is to make enormous profits from the pain and suffering of patients while providing little in return,” said DeMoro.

Despite numerous aspects of the proposed legislation that prompted BusinessWeek in August to feature a cover story headlined “Health Reform: Why Insurers Are Winning,” AHIP is now protesting it is not getting enough following amendments in the Senate Finance Committee reducing penalties for those who fail to buy private insurance.

Overall, the Finance Committee bill in particular will “still constitute a stunning, massive bailout for the insurance industry,” said DeMoro. Components of that bailout include:

* The individual mandate requiring all those without coverage to buy private insurance; even if the penalty is reduced, still worth tens of millions of new paying customers.

* Subsidies for moderate income people to buy insurance.

* No meaningful price controls on what insurers can charge in premiums, co-pays, deductibles, co-insurance and other fees.

* No meaningful reforms on insurance denials of care recommended by doctors that the insurers don’t want to pay for.

“It’s long past time for our elected leaders in Congress and the Obama administration to acknowledge that the problem today is not a public option, it’s the private option. The private insurers are at the heart of everything that is wrong with our present system and why it is failing in access, cost and quality.”

* Insurance premiums over the past decade have already gone up 138 percent, 3.5 times higher than family incomes. In addition, insurance deductibles, co-pays, and co-insurance have been skyrocketing, to thousands of dollars a year for families, especially those with the cheaper insurance plans.

* Six of California’s largest insurers reject on annual average nearly one-fourth of all payment claims, according to a report last month by CNA/NNOC. The state attorney general is currently investigating. Refusal to pay claims or delays in payment results in increased revenues for the insurance giants.

* The top 18 health insurance firms made $15.9 billion in profits last year.

Among the consequences —

* The number of uninsured is up to 46 million; millions more are under-insured (people with limited plans that leave them vulnerable in the event of unexpected health emergencies).

* More employers are shifting costs to employees, or dropping coverage entirely.

* Medical bills are now the principle factor in 62 percent of personal bankruptcies.

* More than half of Americans, the majority of them people with insurance, are skipping needed care due to high out-of-pocket costs.

The best way to respond to this crisis, said DeMoro, “is to remove the obstructionist and interfering role of the insurance industry entirely by expanding and updating Medicare to cover everyone.”

The House is expected to vote on a Medicare for all amendment this month by Rep. Anthony Weiner. CNA/NNOC is urging all legislators to support it.

CNA/NNOC represents 86,000 registered nurses in all 50 states, and is working toward unification with the Massachusetts Nurses Association and United American Nurses to build a new 150,000 member national nurses organization.

Corporate Welfare Is Health System Waste

By Joe Jarvis, MD
Deseret News (Salt Lake City, Utah)
Tuesday, October 13, 2009

I first heard the term lemon socialism articulated by Simon Johnson, who is the former Chief Economist at the International Monetary Fund, now at M.I.T.’s Sloan School of Management. He defines lemon socialism as a system wherein financial successes are credited to the private sector, while their failures are transferred to the taxpayers through bailouts. Anyone who has paid attention to our nation’s financial woes recognizes how lemon socialism is a most apt description of the American economy.

It is also applicable to our health care system, though here better called lemon cherry socialism. Health care costs Americans $2.5 trillion this year, approaching 20% of our gross domestic product. Most of that (60%) is paid by taxation. Many years ago, health insurers did not want the responsibility of paying for the health problems of the poor and elderly (two groups of health care lemons), so they pushed those populations onto the taxpayers’ shoulders. However, health insurers realized that some of the beneficiaries of government programs are relatively healthy (the proper industry term here is cherries, as in ‘cherry-picking’), and so they lobbied successfully for the ‘business’ opportunity to provide health financing to selected groups of these patients, in Medicaid managed care and Medicare Advantage plans. These plans actually cost the taxpayer more than traditional government programs, because the private health insurance business model is all about avoiding risk, not managing it. The plans inventively enroll healthier people and take their government subsidies while they are well, and then push them back into traditional government programs when they become sick and need care. The private sector picks the cherries and the public sector gets the lemons. American socialism, better known as corporate welfare, at its finest.

Health insurers are not alone in learning how to play this game. Mike Leavitt is fond of telling the story of his attempt to change the way Medicare pays for durable medical equipment. On his watch as Secretary of Health and Human Services, staff organized a trial competitive bidding process for expensive equipment needed by Medicare patients, and demonstrated savings up to 46%. The program was killed before it became standard policy, however, when medical equipment sellers used lobbying to induce their representatives in Congress to obstruct the HHS attempt to reduce taxpayer costs. Medicare Part D, the pharmacy benefit for seniors, is yet another example of lemon cherry socialism. We set up a pharmacy benefit program and then asked the pharmaceutical firms how much they wanted to charge the taxpayers for the drugs. Americans pay far more for brand name medications than do the citizens of other countries. Lemon cherry socialism is really corporate welfare.

Bill Moyer recently said: “Over the last two decades, the current members of the Senate Finance Committee have collected nearly 50 million dollars from the health sector. A long-term investment that’s now paying off like a busted slot machine. . .A century ago, muckraking journalists reported that large corporations and other wealthy interests virtually owned the Senate, using bribery, fraud, and sometimes blackmail to get their way. Jokes were made about the Senator from Union Pacific or the Senator from Standard Oil.”

One of the muckraking journalists of a century ago, David Graham Phillips wrote an article in 1906 titled “The Treason of the Senate.” He wrote: “Treason is a strong word, but not too strong, rather too weak, to characterize the situation in which the Senate is the eager, resourceful, indefatigable agent of interests as hostile to the American people as any invading army could be.”

We are witnessing another round of corporate welfare from Congress masquerading as health reform. Neither political party is acting in the interest of patients and taxpayers, but they are eagerly pouring lemon cherry entitlements for corporate hogs at the public trough. No change in our health system is sustainable unless your member of Congress becomes no longer the Senator from Aetna/Cigna/Big Pharma.

Alabama doctors' Rx: an improved Medicare for All

By Pippa Abston, MD, PhD and Huntsville-area physicians.
Huntsville Times
Sunday, October 11, 2009

We are your doctors, and we are frustrated. Frustrated over endless insurance paperwork and denials of coverage. Frustrated that our patients can’t choose their own doctors because of insurance restrictions; frustrated when our patients lose their insurance coverage and can’t afford medical care.

We have seen patients go bankrupt trying to pay for life-saving treatments, or forgo preventive services that might have helped them live longer, healthier lives. And we have been devastated to witness our patients suffering and even dying prematurely because of inability to afford care.

Private insurance companies have raised premiums in Alabama 95 percent since 2000. And instead of using our money to improve our health, it has kept those profits for itself.

Each week, 19 Alabamians die from being uninsured, and 600 more lose their insurance. Alabama health care providers lose over $1.3 billion a year in bad debt – and that gets passed on to you.

We believe health care is a human right, and that medicine is a profession.

When you come into our offices, we do not want to have to check your insurance coverage before we decide if we will be allowed to see you or whether you can afford the care we recommend.

We want to be able to make decisions with you based on our skills, experience, and the best medical evidence, and we want to know that whatever care we decide you need, you will be able to get it.

That’s why many Alabama physicians have joined the thousands of doctors who belong to Physicians for a National Health Program.

We believe the best moral, medical and financial solution is an improved and expanded Medicare for all. Such a program, detailed in bill HR 676 by U.S. Rep. John Conyers, D-Mich., would allow private practice doctors to see patients with government-funded insurance.

Universal coverage would provide all Americans with comprehensive medical benefits – coverage for doctors’ visits, hospital stays, lab tests, X-rays, dental care and medications.

You would know, before going to the doctor, that you would be able to get what you need to stay healthy. You would not have to split your pills because you couldn’t afford the whole dose, or delay going to the doctor until your problem can’t be fixed.

This would be an easily affordable plan. By eliminating private insurance overhead, and replacing insurance premiums with a much smaller payroll tax, we could take care of every person in this country without adding anything to our national debt.

We would increase our productivity with healthier workers. We could solve our mortgage crisis – most bankruptcies are caused by health care debt.

And we would have to cover fewer people on disability by providing timely medical care.

We want you to know that care is being rationed every day in our offices, and this is unacceptable. For the insured, it is rationed by what insurance companies will cover. For the uninsured, it is rationed by being completely unaffordable. Instead of this rationing, we want all patients to have access to care.

We want our patients, both young and old, to be treated with respect. It upsets us that our elderly patients will not only die years earlier than they would in countries with universal care but also be less healthy in their remaining years.

We know that if we had universal coverage, we would be able to provide needed services to our older patients as well as keeping our children healthy.

Some people think our patients can get health care at the ER. But the ER will not give you preventive care for high blood pressure.

It will take care of you when you have life-threatening bleeding in your brain from untreated hypertension – and after you are sent home from the hospital, partly paralyzed and unable to speak, it will get whatever payment it can from you, including your home.

We have decided in the past to have certain rights as citizens, rights we all enjoy equally – for example, the right to vote, to a fair trial and to a free public education.

Health care is also, we believe, a human right. As such, it should be offered to all citizens, without discrimination.

We are your doctors, and we are frustrated, but we are also hopeful.

We believe that the U.S. can improve its health care system so that our patients live as long as patients in other developed countries. And we believe this can be done while saving money, improving quality, shortening wait times, and putting a stop to rationing of care.

Please help us take care of you, our patients.

Read about universal coverage at www.pnhp.org and get the truth.

Then contact your senators, representatives and the president to insist that they put your needs ahead of wealthy insurance companies. Tell them you want real health care reform.

[This article originally appeared under the headline “Doctors say health insurance system needs healing but find no easy cures.”]

Huntsville Area Doctors Favoring a Government Health Care System: Drs. Pippa C. Abston, Robert H. Creech, D. Wayne Laney Jr., Lola T. Brown, Celia Lloyd-Turney, J. Walden (Wally) Retan (Birmingham), Ronald M. Wyatt

http://www.al.com/opinion/huntsvilletimes/editorials.ssf?/base/opinion/125525263179690.xml&coll=1

Health care: The uncivil rights movement

By Tim Louis Macaluso
City Newspaper (Rochester, N.Y.)
September 16, 2009

The national debate over health-care reform blazed through the summer with fiery town hall speeches and angry protests from both the right and the left. The far-fetched charges were nothing short of astonishing in their sheer absurdity and bitterness.

But wild-eyed fights over health care are nothing new in American politics. The struggle for universal coverage has been going on for more than 100 years, says Theodore Brown, a history professor at the University of Rochester. Brown has chronicled the history of health care in the US. He describes it as a long series of charge-and-retreat scuffles between liberals and conservatives that have led us to where we are now – with a costly, broken system.

Brown’s support of Representative John Conyers’ single-payer plan during an event at the Rochester Museum and Science Center earlier this year landed him on YouTube. The clip is called “A Century of Health Care Reform in 8 Minutes.”

At the turn of the 20th century, few Americans had health coverage of any kind. But as Great Britain and Germany began to experiment with government-run health care, Americans began organizing in favor of it, too. It was quickly squelched by opponents, however.

In a recent interview with City Newspaper, Brown said that meaningful health-care reform is only possible through universal coverage, ideally through a single-payer plan. Universal coverage would achieve two main goals: covering all Americans and reducing the cost of health care.

Brown said that health care is intrinsically linked to the US economy. Amorphous and fluid, health care is not only a sector of the economy, but it flows through and influences nearly all other parts of the economy. For the US to remain competitive, Brown said, health-care costs need to be controlled.

Democrats may have jumped into the latest health-care battle unprepared and too eager to appear bipartisan, he said. By not starting with a single-payer solution, Brown said, Democrats lowered the bar for compromise to the point where even a strong public option isn’t certain. The result, Brown said, could be a jumbled bill that achieves little, and pleases no one.

While he appreciated President Obama’s September 9 speech, its clear identification of the problems, and Obama’s willingness to confront truth-distorting tactics, Brown said that he is disappointed in the president’s plan. “I don’t believe that many of the reforms suggested will realize the savings or generate the revenues they are supposed to,” he said.

The following is an edited version of an interview with UR professor of history, Theodore Brown.

CITY: Can you give a brief history of health-care coverage in the US? Hasn’t there always been some resistance to it?

Brown:The effort to reform the American health-care system in the direction of more universal coverage where the government would play an important role as the financier and provider of care goes back over a century. Probably the first, most important moment was at the convention for the Progressive Party in 1912, which nominated Teddy Roosevelt. He broke with Republicans and he was running as a third-party candidate that had a major progressive platform. One of the planks on that platform was something called “sickness insurance.” At the time, it would have been a basic insurance plan.

There was a lot of support for this. A lot of organizations came on board. Even the American Medical Association was supporting it for a while.

A major turning point was 1917 to 1918, which involved the United States entering into World War I and the Russian Revolution. There were opponents [to the plan] all along, but they now beat the drum very loudly. This was the first tarring and labeling of the plan as socialistic and un-American.

In the period immediately after World War I, there was a major Red Scare and backlash similar to the post-World War II-McCarthy era. Much of the progressive-era plan fell through.

Truman became the first sitting president to strongly promote national health-insurance reform. Immediately after World War II, the American Medical Association, the insurance industry, and conservative politicians began to mobilize very strongly against Truman. He was a New Deal Democrat, and saw health-care insurance reform as a natural extension of the New Deal.

This was seen as a very dangerous step by the conservative forces and their allies. An incredible campaign was launched of deliberate obfuscation, mislabeling, and placing editorial cartoons. The AMA, to its great discredit, pioneered some of the techniques that have been perfected today. That then fed right into the Red Scare and McCarthy era. Essentially, those on the liberal end of the spectrum got scared off.

Unfortunately, I see a real parallel with what’s happening now with people getting scared away from the public option.

Why is health-care coverage important to a modern country? And assuming it is important, is it a right or a privilege?

My personal view is that it should be a right; that it should be a basic right of citizenship like public education, clean water, good air quality, and so on. Ethically and morally, I do think it is a right.

But it also makes eminent economic sense. It is the only wise way to organize and mobilize resources. Health-care costs are now something like 16 percent of the GDP, and going up. Soon the figure will be 20 percent. And there is no end in sight.

There was some enthusiasm for a single-payer plan earlier in the year. Now we’re into September and it’s not even discussed. What happened?

Well, it’s not completely gone. There’s been a lot of screaming going on, and those on the left backed away. They’ve gotten scared off, again.

I just read something this morning, an interesting strategy article that said the best way to have advanced a reasonable public option would have been to have the Democratic leadership come out strong for single-payer. Then the public option would have seemed more moderate and mainstream.

Some have even suggested that if you want to get single-payer passed, then we should opt for something like the VA system or the National Health Service of England.

But the center has moved to the right. And a lot of that has been engineered. And the Obama administration, in my view, has succumbed to that. They have backed away and backed away, instead of standing straight in the face of it.

Now, to your point about single-payer – it hasn’t disappeared. New York Representative Anthony Weiner has gotten the Democratic leadership to allow a floor debate on a single-payer bill. They have been introduced since the 1980’s, but they have never gotten out of committee. The single-payer bill, at its peak, had about 93 to 95 sponsors. Weiner has been very effective. He’s made the case and has apparently gotten time to debate this on the floor.

It will no doubt go down to defeat, but it will not go away.

Dissect some of the criticisms of the public option – that it will put private insurance companies out of business and that it will stifle innovation.

I think Obama said it very well back in July. He said, “What are they afraid of? If the private insurance industry does so well, then they should win hands-down.”

Are they afraid that the public option can deliver care as efficiently, and less expensively? Isn’t it the American way to have toe-to-toe competition?

Whether they will stifle innovation, this is another fabricated propaganda claim propagated by the pharmaceutical industry. The facts are that most of the so-called research and development funding [invested] by the pharmaceutical companies is trivial in comparison to the money the industry takes in profit, invests in marketing, and pays its senior management.

Fact two: A considerable amount of the research and development funding really comes from the National Institute of Health – the taxpayer.

And fact three: Many of the most recent innovations and advancements have come from Europe and Japan, where they have national health systems. The CAT scan, for instance, was developed in England.

These are lies that are repeated often enough to get people to believe them.

Is it possible to have reform without a public option?

There will be reform of some kind. We’ll have some tort reform to reduce the amount of litigation. Covering people with pre-existing conditions will probably pass. We’re already trending in that direction. And maybe there will be some portability of benefits.

Of course, these are all good things. But are they good enough? Or are they just taking the pressure off so the system doesn’t bubble over?

Will this change the trend in extraordinarily high health-care costs? No. Will it change anything fundamentally that leads to a more universal system that covers everyone? No.

How can we control costs, and what happens if we don’t?

If we don’t, we’ll go broke. More major industries will fail because the cost of continuing to try to provide health-care coverage for their workers is unsustainable – certainly not in a global market.

We know that we currently spend $300 billion a year for unnecessary overhead in health-insurance coverage – the high administrative costs, the marketing, and so on. We know that the Medicare system is a much more efficient and cost-effective system. There are some overhead costs, of course.

But one of the reasons that our current system is so incredibly expensive is because we duplicate and triplicate services. And we have to have these large billing departments in hospitals.

If you moved to a single-payer system, that move alone would save billions annually, which could be used to cover all of the uninsured without raising a single penny in taxes.

The Obama administration has painted itself into a corner. They say reform is going to cost $1 trillion over a 10-year period. My question is why? Because they are not going to a single-payer system, and they still have to factor all of those costs in to whatever they do.

Here’s the kicker: At minimal funding, the British system costs about one-third per capita of the US system. The Canadian system costs Canadians about half to five-eighths per capita of the US system. Yet, they cover everyone and the outcomes are much better. Their life expectancy and mortality rates are far superior to the United States. We pay much more and get far less. That’s the bottom-line reality.

Critics say that there is a conflict of interest in the current fee-for-service health-care system because outcome is secondary to the number of services rendered. But aren’t most industries concerned with how many widgets or services they can sell you?

Fee for service still controls a lot of doctor-patient interactions, but the difference here is that there are so many third-party insurance intermediaries, and a lot of the shots are called by the insurance companies – not by you or your doctor. So, your options are limited.

The most salient part of the whole health-care economic reality is that the third party wants to make a profit. We know the insurance industry is a massive and profitable industry. It’s almost a recession-proof business. And the way they make their money is you pay in via your premiums, and you presumably collect when your physician says you need care or treatment.

But the physician has to submit this for reimbursement to the insurance company that says “We’re only going to pay a certain amount,” or “We’re not going to pay anything at all,” or “We want another opinion.” It’s the hassle factor. They make their profit by taking in X and giving you back less than X.

Medical loss ratio is an insurance term. A medical loss defined by the insurance industry is what they have to pay out of every premium dollar they take in. If they take in $1 and pay 80 cents, the medical loss ratio is eight to 10. Think of what that means. In their minds, anything they pay in terms of medical care is a loss. I find that chilling, but it’s a reality.

Medicare has been characterized as corrupt, bloated, and an inefficient government-run system. But most doctors, nurses, and technical staff see Medicare patients, in addition to their private-insurance patients. Wouldn’t that make both systems corrupt and bloated?

Well, in fact, it’s much sparer in the government-run Medicare system.

But even with that, 59 percent of the members of the American College of Physicians polled still thought there would be less hassles and difficulties with a government-run system, and would prefer going to a Canadian-style system.

One of the great contradictions in this debate is the argument that we don’t want a government-run public option because that is socialized medicine. But Medicare-for-all would not be a socialized system. It would be a continuum of care across the age spectrum, keeping the system intact. It would be the same hospitals with the same medical staff.

Would there be a need for some type of supplemental insurance like there is with Medicare now?

I don’t see any problem with that. That’s the tendency in Britain and other countries. But the important thing is to not set them in opposition to one another and create a robust public plan that people can supplement if they want.

In terms of controlling costs, do the plans being discussed need more emphasis placed on preventative care?

That’s always a thorny issue. There are slow changes underway in that direction.

One important step taken by the Obama administration that has flown under most people’s radar is talk about reinstating the physician payment commission. Under Medicare, physicians are being paid for certain procedures. But the commission could add incentives for more preventive medicine. In Medicare, that’s already happening. But it should become more widespread.

Toyota is moving its US manufacturing plant overseas. It turns out overseas is really Ontario, Canada, where they don’t have to cover health insurance for their workers. Is there any way to separate the discussion of health-care coverage from the economy?

No, absolutely not. America has dug itself into a major hole. It’s made itself much less competitive because it has added health care to the cost of production. It’s part of our labor costs.

We’ve known for years that the economy and employment are being driven by small businesses, and now we’re entering the age of the independent contractor and telecommuter. How can health care coverage remain linked to the employer?

The country began to notice that this uninsured population really increased in the 1980’s. One journal described how it went from a dilemma to a crisis in the years that followed.

Fundamental changes in the American economy – moving jobs offshore, moving manufacturing from Democratic states like Michigan and New York to Southern states where there is no support for unions – all of these moves to increase profitability served to reduce the employment base for health insurance. And it has made this link between coverage and the employer base even crazier.

If the goals are to cover everyone, keep quality of care high, and costs down, what should President Obama tell Congress and the public?

The single-payer plan is the most feasible. My advice is to take the political risk. Make it a moral-ethical campaign.

If you asked anyone in 1950, particularly in the South, whether African Americans could be granted the right to vote and be elected into office, it was inconceivable. But we had something called the civil rights movement, which didn’t argue that it was economically wise or politically stabilizing. They made the claim, Dr. Martin Luther King and others, that it was a matter of human dignity. It’s just the right thing to do. And it mobilized change.

And I think there are enough people out there who see health care in a similar way, and who can be mobilized.

Crush of cancer, medical bills snares family

By Stephanie Smith
CNN Medical Producer
Tue October 13, 2009

WEST PALM BEACH, Florida (CNN) — Leslie Elder’s eyelids fluttered open, and through the fog of pain medication, she saw the emergency room doctors pull back the curtain in her room.

She could tell that the news was bad.

“They didn’t have to say a word. I knew from their faces that something wasn’t right,” said Elder, 60, who hours earlier had stumbled into the ER with a stabbing pain in her abdomen. “Then one doctor said, ‘Your right kidney … it’s breaking apart. You have a tumor … and you also have a tumor in your left kidney.’ ”

The words “You have a tumor” were not new to Elder; her grim financial situation was.

Elder had cancer twice before — in 1988, doctors found a tumor in her right breast, and in 2001, they found one in her left breast — except back then, she was insured. By the time she learned that she had kidney cancer in September 2005, she was uninsured.

“All I could think of was ‘Oh, my god, I’m going to go broke. We’ll be living in a cardboard house,’ ” Elder said. ” ‘How am I going to do this?’ It was the most honest feeling of powerlessness.”

Insurance conflict

Elder and her husband, Jim, say their health insurance carrier, Nationwide Insurance, forced them into an impossible situation by raising the rates on their policy over several years. Eventually, they were forced to cancel.

“Nationwide denies any inference that the company inappropriately raised rates for the coverage that was provided from 1987 until the time the Elders canceled the policy,” spokeswoman Liz Christopher said in a statement.

The Elders are broke and on the cusp of bankruptcy because of medical bills, and they’re not alone. A study published in the June issue of the American Journal of Medicine found that in 2007, 62 percent of personal bankruptcies were because of medical debts. The same study indicated that in 1981, only 8 percent of bankruptcy filings could be traced to medical bills.

“Health insurance premiums track directly with the underlying cost of medical care,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, which represents 1,300 health insurance carriers in the United States. “As the cost of providing care increases, premiums increase accordingly.”

The Elders boil it down to health insurance companies putting profits ahead of human life. VideoWatch more on the Elders’ struggle Â»

“The insurance companies are choosing who will live and who will die,” Leslie Elder said.

Nationwide Insurance says it did not break any law by increasing the Elders’ insurance premium.

“Health insurance rates were and are highly regulated by various state insurance departments, and any premium increases for the Elders and other policyholders would have been made in full compliance with state laws in effect at that time,” Christopher said.

The Florida Department of Insurance Regulation, which oversees companies like Nationwide, said in a statement, “There is no law that limits the amount of rate requested by an insurer.” Insurance officials add that their office reviews all rate requests, ensuring that the requests are not excessive or discriminatory.

The Elders bristle at the notion that their experience could be cast as anything but “excessive” and “discriminatory.”

Health care bills before the Senate and House are designed, in part, to rid the market of health care discrimination, especially as it relates to pre-existing conditions like Elder’s cancer.

Zirkelbach says the industry agrees with removing pre-existing conditions from consideration for pricing policies but stresses that reform should not come by way of raising taxes or cutting benefits for other programs like Medicare.

The Obama administration has said repeatedly that health care reform would not cut benefits or raise taxes.

The Elders are not hopeful that health care reform — even if it excludes pre-existing condition clauses from health insurance policies — will help them any time soon.

According to the bill currently before the House, it will be 2014 before self-employed families like them will actually have access to health insurance. By then, Elder will be near eligibility for Medicare.

While the debate in Congress continues, Elder says she is waiting anxiously — waiting for reform, and for her cancer to come back.

A contentious relationship

The Elders did not always have such a contentious relationship with their health insurance carrier, and they were not always broke. In fact, before their insurance troubles, they were solidly middle-class business owners.

However, in 1988, things began changing. It was the year of Elder’s first breast cancer diagnosis. When the family’s plan required payment of a $250 deductible and a 20 percent share of the costs of medical care, the Elders could afford it.

Years after that first diagnosis, things started getting shaky. Jim Elder says the premiums crept up slowly at first and then more dramatically.

“You do ask why, why, why,” Jim Elder said. “Why are we stuck with all these huge bills when we’re supposedly covered?”

A recent Kaiser Family Foundation study examining U.S. health insurance policies generally found that from 1999 to 2009, the average family premium more than doubled. The Elders say that over the life of their Nationwide Insurance policy, their premiums nearly quadrupled.

The Elders believe that their health insurance premiums soared higher than those of the average family because of Leslie’s previous cancer diagnosis.

“What is the message here? Survive cancer but then go drop dead because we can’t make any money off you anymore?” Leslie Elder asked. “[The insurance companies] figure, ‘You’re useless. Get lost.’ ”

Nationwide says, “While we’re empathetic to the Elders’ situation, we stand by the policy coverages provided to the Elders while they were customers.”

To cope with high premiums, the Elders played a precarious, yet common, game. They increased their deductible to offset the high premiums. By the time Leslie Elder got breast cancer for a second time, in 2001, the family’s deductible was up to $5,000.

What happened next would send shock waves through the Elder household.

“As I’m recuperating, I receive $21,000 of bills that I was responsible for,” Leslie Elder said. Under the Elders’ policy with Nationwide they did, in fact, owe so much, in part because of rising health care costs, and in part because their deductible was now so high.

She was stunned and confused — not just about the bills but about how they were going to pay. What still confounds Leslie and Jim Elder: How the cost of medical care, and medical insurance, went sky high in just over a decade.

Late in 2001, the Elders were scrambling for affordable coverage. They dropped their policy with Nationwide Insurance and signed up for a more affordable policy with Aetna, by starting a group policy including employees in a small business they were running at the time. Eventually, Aetna would increase the Elders’ premium to nearly $1,000 per month. It was too much. In 2005, the Elders dropped their health insurance policy for the second time.

“I sat down and seriously thought about it for a long time and said, ‘I’m not going to do this,’ ” Leslie Elder said. “I am not going to pay. Never mind ‘I’m not going to’; there was no way I could.”

In a statement, Aetna said that Leslie Elder’s previous cancer diagnoses were not the culprit for the rate increase.

Although the company did not cite a specific reason for the increased rate, Cynthia Michener, an Aetna spokeswoman said: “There can be other contributing factors to rate increases for small business policies, including, for example, the aggregate cost of the entire pool of small business policies in the state.”

Zirkelbach said, “Everybody who has health care coverage should have the peace of mind that their coverage is going to be there when they need it. We have proposed to eliminate pre-existing condition exclusions entirely so that everybody has peace of mind that coverage will be there, that they won’t be paying based on their health status.”

Through it all, there was one bright spot: A generous family member paid the more than $80,000 in hospital bills stacked up during Leslie Elder’s 2005 kidney cancer treatment. Still, the family is struggling to pay down the bill of more than $21,000 from 2001.

Leslie Elder says that even if she could afford it, because of her pre-existing condition, she is “uninsurable.” Without coverage, she cannot afford follow-up exams for cancer, so Elder has no idea whether her cancer has come back. In a strange way, she says, not knowing is better.

“I don’t think I could bear to listen to those words again. … ‘You have cancer,’ ” Elder said. “I’ve said to my husband, if I start to get sick, just set me up with a nice pill cocktail on a beach, because nobody cares. That’s the message you hear every day from insurance companies.”

What about primary care?

"Uncomplicated" Primary Care?

By Josh Freeman
Medicine and Social Justice
October 8, 2009

I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.

However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position.

Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from (their Physicians Foundation report) they note:

“Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care.”

The American Academy of Family Physicians (AAFP) in its formal response to the Physicians Foundation report includes the following:

“This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as ‘anomalous’ and ‘simple frameworks’ without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”

Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care”. What is this “uncomplicated primary care” of which you speak?

The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult.

(Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He is author and editor of the Medicine and Social Justice blog.)

http://medicinesocialjustice.blogspot.com/2009/10/uncomplicated-primary-care.html

And…

Health Bills In Congress Won’t Fix Doctor Shortage

By Phil Galewitz
Kaiser Health News
October 12, 2009

Even as Congress moves to expand health insurance coverage to millions of Americans, it’s doing little to ensure there will be enough primary care doctors to meet the expected surge in demand for treatment, experts say.

The American Academy of Family Physicians predicts that the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine.

A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions — a 15 percent increase that would favor more primary care training — was considered dead on arrival because of its $10 billion price tag over a decade.

Instead, the House and Senate overhaul bills would redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies.

Proposals to significantly increase Medicare payments for primary care doctors have gone nowhere in part because the money would come from payments to higher-paid specialists — who, not surprisingly, oppose a pay cut.

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said the extra training slots emanating from the redistribution of unfilled residency position would amount to a “drop in the bucket.”

http://www.kaiserhealthnews.org/Stories/2009/October/12/primary-care-doctor-shortage.aspx

Comment:

By Don McCanne, MD

One of the promises of reform was to reinforce our primary care infrastructure. Although there are a few measures in the bill such as a nominal primary care bonus and a medical home pilot project, failure to train more primary care physicians will require many patients to rely on expensive care in our emergency rooms and expensive care through often inappropriate, direct self-referral to specialists.

We were promised that everyone would be covered and costs would be controlled. Neither will happen. And now the promise of providing primary care access to everyone will fall far short. Jiggling 1000 existing medical residencies just won’t do it.

Senate Finance bill is no solution to health care crisis

FOR IMMEDIATE RELEASE
Oct. 13, 2009

Contact:
Quentin Young, M.D., (312) 782-6006
Mark Almberg, (312) 782-6006, cell: (312) 622-0996

Dr. Quentin Young, national coordinator of Physicians for a National Health Program (www.pnhp.org), made the following statement today:

“The Senate Finance Committee bill, which passed this afternoon in committee, preserves all the systemic deficiencies that we see in our present health care financing model. It maintains a system that is based on private insurance and for-profit, private insurers. It therefore cannot and will not provide truly universal, comprehensive and affordable care.

“According to the Congressional Budget Office, the bill, even with its mandate requiring people to buy insurance, will leave 25 million people uninsured. An even greater number will be underinsured, i.e. vulnerable to financial ruin in the event of a serious illness.

“The Senate bill will be unable to contain costs, which are projected to double in the next decade.

“While it is possible to temporarily expand coverage by subsidizing the purchase of private coverage, as the Senate bill does, such an approach is not sustainable. It won’t cover everybody and it will fall apart quickly due to rising costs, as we’ve seen with similar approaches in Massachusetts, Vermont, Oregon, Tennessee and Minnesota.

“The insurance companies’ drive to fight claims, issue denials, screen out the sick and make a big profit generates tremendous administrative waste — $400 billion a year.

“In contrast, by replacing our dysfunctional, for-profit, multi-payer system with a streamlined, nonprofit social insurance program — single-payer Medicare for All — we can recapture the $400 billion that is presently wasted on bureaucracy and paperwork and use that money to provide comprehensive, high quality care for everyone. And we won’t have to spend a penny more than our nation does now.

“There’s no getting around the fact that single-payer Medicare for All remains the only realistic solution to our profound health care crisis. As big as the challenge may be, Congress should act accordingly.”

Physicans for a National Health Program is an organization of 17,000 doctors who support single-payer national health insurance. For more information, visit www.pnhp.org or call (312) 782-6006.

Nurses Blast Latest Price Gouging Threat by Insurance Giants, ‘Massive Public Bailout Apparently Not Enough’