By Michael M. Rachlis
Los Angeles Times
August 3, 2009

Universal health insurance is on the American policy agenda for the fifth time since World War II. In the 1960s, the U.S. chose public coverage for only the elderly and the very poor, while Canada opted for a universal program for hospitals and physicians’ services. As a policy analyst, I know there are lessons to be learned from studying the effect of different approaches in similar jurisdictions. But, as a Canadian with lots of American friends and relatives, I am saddened that Americans seem incapable of learning them.

Our countries are joined at the hip. We peacefully share a continent, a British heritage of representative government and now ownership of GM. And, until 50 years ago, we had similar health systems, healthcare costs and vital statistics.

The U.S.’ and Canada’s different health insurance decisions make up the world’s largest health policy experiment. And the results?

On coverage, all Canadians have insurance for hospital and physician services. There are no deductibles or co-pays. Most provinces also provide coverage for programs for home care, long-term care, pharmaceuticals and durable medical equipment, although there are co-pays.

On the U.S. side, 46 million people have no insurance, millions are underinsured and healthcare bills bankrupt more than 1 million Americans every year.

Lesson No. 1: A single-payer system would eliminate most U.S. coverage problems.

On costs, Canada spends 10% of its economy on healthcare; the U.S. spends 16%. The extra 6% of GDP amounts to more than $800 billion per year. The spending gap between the two nations is almost entirely because of higher overhead. Canadians don’t need thousands of actuaries to set premiums or thousands of lawyers to deny care. Even the U.S. Medicare program has 80% to 90% lower administrative costs than private Medicare Advantage policies. And providers and suppliers can’t charge as much when they have to deal with a single payer.

Lessons No. 2 and 3: Single-payer systems reduce duplicative administrative costs and can negotiate lower prices.

Because most of the difference in spending is for non-patient care, Canadians actually get more of most services. We see the doctor more often and take more drugs. We even have more lung transplant surgery. We do get less heart surgery, but not so much less that we are any more likely to die of heart attacks. And we now live nearly three years longer, and our infant mortality is 20% lower.

Lesson No. 4: Single-payer plans can deliver the goods because their funding goes to services, not overhead.

The Canadian system does have its problems, and these also provide important lessons. Notwithstanding a few well-publicized and misleading cases, Canadians needing urgent care get immediate treatment. But we do wait too long for much elective care, including appointments with family doctors and specialists and selected surgical procedures. We also do a poor job managing chronic disease.

However, according to the New York-based Commonwealth Fund, both the American and the Canadian systems fare badly in these areas. In fact, an April U.S. Government Accountability Office report noted that U.S. emergency room wait times have increased, and patients who should be seen immediately are now waiting an average of 28 minutes. The GAO has also raised concerns about two- to four-month waiting times for mammograms.

On closer examination, most of these problems have little to do with public insurance or even overall resources. Despite the delays, the GAO said there is enough mammogram capacity.

These problems are largely caused by our shared politico-cultural barriers to quality of care. In 19th century North America, doctors waged a campaign against quacks and snake-oil salesmen and attained a legislative monopoly on medical practice. In return, they promised to set and enforce standards of practice. By and large, it didn’t happen. And perverse incentives like fee-for-service make things even worse.

Using techniques like those championed by the Boston-based Institute for Healthcare Improvement, providers can eliminate most delays. In Hamilton, Ontario, 17 psychiatrists have linked up with 100 family doctors and 80 social workers to offer some of the world’s best access to mental health services. And in Toronto, simple process improvements mean you can now get your hip assessed in one week and get a new one, if you need it, within a month.

Lesson No. 5: Canadian healthcare delivery problems have nothing to do with our single-payer system and can be fixed by re-engineering for quality.

U.S. health policy would be miles ahead if policymakers could learn these lessons. But they seem less interested in Canada’s, or any other nation’s, experience than ever. Why?

American democracy runs on money. Pharmaceutical and insurance companies have the fuel. Analysts see hundreds of billions of premiums wasted on overhead that could fund care for the uninsured. But industry executives and shareholders see bonuses and dividends.

Compounding the confusion is traditional American ignorance of what happens north of the border, which makes it easy to mislead people. Boilerplate anti-government rhetoric does the same. The U.S. media, legislators and even presidents have claimed that our “socialized” system doesn’t let us choose our own doctors. In fact, Canadians have free choice of physicians. It’s Americans these days who are restricted to “in-plan” doctors.

Unfortunately, many Americans won’t get to hear the straight goods because vested interests are promoting a caricature of the Canadian experience.

Michael M. Rachlis is a physician, health policy analyst and author in Toronto.

Dr. David Scheiner Was President’s Physician For 22 Years

CBS News, Channel 2, Chicago
Jul 31, 2009

WASHINGTON (CBS) — President Obama’s very own doctor thinks his proposed health care reform pushing government-run insurance is “a bad program,” according to media reports.

Dr. David Scheiner, Obama’s personal physician for 22 years when the then-senator lived in Illinois, told the Chicago Tribune, “I don’t think it’s what he feels in his heart is necessary. I think it’s what he feels politically is the best way.”

The 70-year-old doctor based in the Chicago area is an advocate of single-payer health care systems — through which a single entity, like the federal government, pays fees to hospitals and doctors.

He said he is troubled the president has consulted with private industry executives more than primary care physicians and has not talked more about the benefits of single-payer coverage, according to CBS News.

Obama years ago said he was a proponent of a single-payer system but has since said such a program is not feasible given the current, employer-based structure of the nation’s health care system. The president has left many of the details of health care reform up to Congress, encouraging them to come up with a bipartisan plan.

Scheiner issued a statement July 30 arguing for a single-payer approach to health care reform:

“Some critics attack single-payer, arguing that under such a program, government bureaucrats will be between the patient and the physician. In the 40 years I have been practicing under Medicare, I have never encountered an instance where Medicare has prevented proper medical care. On the other hand, insurance companies frequently interfere and block appropriate care.

“There are multiple problems with the present congressional health reform proposals, but allowing private insurance to continue being involved is the most egregious. The insurance companies actually like many of the proposed reforms, including the requirement that every American purchase insurance or suffer a tax penalty, which would be a windfall to the insurance industry. That alone should be a warning.”

In the meantime, lawmakers were still trying to hammer out a plan that would please all parties. Democrats sought to limit increases in the cost of insurance sold under the sweeping health care bill Friday as they labored to clear the final obstacle to a September showdown on President Obama’s top domestic priority.

Several officials said a last-minute agreement among Democrats on the Energy and Commerce Committee also included authority for the federal government to negotiate directly with pharmaceutical companies for lower drug prices under Medicare.

The changes were part of an intensive effort Democrats have made in recent days to satisfy the conflicting demands of liberals and conservatives on the panel. “We have agreed we need to pull together,” said Rep. Henry Waxman, D-Calif., the committee chairman. He said he hoped for a vote by early evening.

Several officials said the cost of insurance to be sold widely under the bill could not rise by more than 4 percent a year unless the government approved.

The officials who disclosed the terms of the last-minute agreement did so on condition of anonymity, saying they were not authorized to discuss private deliberations.

The White House declined to state a position on the changes.

by Bruce Dixon, Managing Editor
Black Agenda Report
July 29, 2009

With the corporate media relentlessly distorting the public discussion around health care reform, it time for some clear, bright lines to help us tell who is doing what to whom, and whether any of it leads to health care for all of us. Here are ten of them.

Barack Obama and Democratic majorities in the House and Senate were swept into office on a promise they would deliver affordable and accessible health care for all Americans. But the corporate media journalism limits the national health care conversation to what insurance companies, drug companies, for-profit health care professionals, their executives, lobbyists and politicians of both parties and other hirelings have to say. So it isn’t as easy as it ought to be to tell what the politicians are doing about accomplishing health care for everybody. Hence we offer these ten points. This is how you can tell whether your president and his party are fighting for the health care you deserve.

1. Their plan doesn’t cover the uninsured till at least 2013.

2013 isn’t “day one.” It’s not even after the midterm election. It’s clear after the president’s second term, if he gets one. Congress passed Medicare in 1965 and president Lyndon Johnson rolled out coverage for millions of seniors in eleven months, back in the days before they even had computers.

22,000 Americans now perish each year because they can’t get or can’t afford medical care, and this year three quarter million personal bankruptcies will be triggered by unpayable medical bills. Why this president and these Democrats are in such a hurry to pass health care now that doesn’t take effect till two elections down the road doesn’t make sense in any kind of good way.

2.Their “public option” isn’t Medicare, won’t bring costs down and will only cover about 10 million people.

The “public option” was sold to the American people as Medicare-scale plan open to anybody who wants in that would compete with the private insurers and drive their costs downward. But in their haste not to bite the hands that feed them millions in campaign contributions each hear, the president and his party have scaled the public option back from a Medicare-sized 130 million to a maximum of 10 million, too small to put cost pressure in private insurers. Worse still, the president and his party are playing bait-and-witch, not telling the public they have reduced the public option, to nearly nothing.

This remnant of a public option is not Medicare, as Howard Dean insists, and it will not lead to the sort of everybody-in-nobody-out health care system that most Americans, whenever they are surveyed say they want.

Some Senate and House Democrats want to ditch even the pretense of a “public option” in favor of something they’re calling a private insurance “co-op”, which as near as anybody can tell has the same relationship to an actual cooperative that clean coal has to actual coal.

3. The president and his party have already caved in to the drug companies on reimporting Canadian drugs, on negotiating drug prices downward and on generics.

This explains why Big Pharma, the same people who ran the devastatin g series of anti-reform “Harry and Louise” ads to spike the Clinton-era drive to fix health care are spending $100 million to run Obama ads using the president’s language about “bipartisan” solutions to health care reform.

4. The president and his party have received more money from private insurers and the for-profit health care industry than even Republicans, with the president alone taking $19 million in the 2008 election cycle alone, more than all his Repubican, Democratic and independent rivals combined.

Democratic senator Max Bacaus got $1.1 million in 2008. Democratic senators Harkin, Landreau and Rockerfeller each got over half a million, and Senator Durbin got just under half a million. Other Democratic senators got a little less. Four Democrats in the House, Rangel, Dinglell, Udall and Hoyer got over half a million apiece in 2008, with other Democrats not far behind.

Is there any wonder that the insurance companies, like the drug companies are also running “bipartisan health care reform” commercials using the president’s exact language?

5. The president’s plan, and those of Republicans and Democratic blue dogs too, will require families to purchase health insurance policies from private insurers.

This is something the policy wonks call an ‘individual mandate”, under which Individuals will be “mandated” to purchase affordable insurance, though companies would not be required to offer it. In Massachusetts, the prototype state for the Obama plan, a family with an income of $33,000 can be required to spend $9,000 in deductibles and out-of-pocket expenses before the insurance company is obligated to pay a dime. As in Massachusetts, public money is used to purchase private insurance for the very poorest citizens. With the revenues of insurance companies on the decline, individual mandate programs are a welcome bailout for the private insurance industry.

6. The president’s plan, and those of Republicans and Democratic blue dogs too, could force you to buy junk insurance.

Think about an insurance policy that costs a lot, but is full of loopholes, exceptions and steep deductibles and co-payments. That’s junk insurance, and for many it’s the only insurance companies offer. Even more pernicious is the widespread practice among insurance companies of “recission” in which claimants are routinely investigated and disqualified in the event that they finally make a claim. Insurance companies admit they do this to half of one percent of policies per year. That means if you hold a health insurance policy twenty years, you don;t have insurance – you have a ninety percent chance of having insurance.

7. The president’s plan, as well as those of Democratic “blue dogs” and Republicans, are to be funded in part with cuts in Medicare and Medicaid.

Private insurance companies have always hated Medicare because it is far more efficient than they are. Medicare’s administrative expenses are under five percent, as compared with the one third of every health care dollar taken by the for-profit insurance companies for their advertising, bad investments, billing and denial machinery, executive salaries and bonuses. Private insurers have, over the years, purchased enough influence in Congress and previous White Houses to restrict Medicare’s payment rates and partially privatize it. But president Obama’s plan, perhaps the most friendly to Medicare and Medicaid, calls for over $300 billion in cuts to the programs that now provide medical care to those with the fewest options, while failing to guarantee that care will come from elsewhere. In Massachusetts right now, hospitals are turning away poor people they used to be able to provide care for because funding that used to go to those institutions is now plowed into the state’s “individual mandate” system.

8. The president, with the cooperation of corporate media and the Republicans is trying to make the argument about himself instead of a discussion on the merits of his policy.

The president and his critics are happy to talk about whether this will be “his Waterloo”, or his Dien Bien Phu, as if that matters more than the 22,000 Americans who die each year from lack of medical care, or the three quarter million who will go bankrupt because of unpayable medical bills. The concentration on whether the president looks good or bad takes up air, ink, and coverage time that might otherwise be spent explaining what is and isn’t in the various proposals, and why.

If the president were not afraid of his own supporters publicly examining the merits and demerits of his proposals, he would mobilize those 13 million emails and phone numbers collected during the campaign. The reason he has not sone so already is that most of his own supporters favor a Medicare-For-All single payer health care system, HR 676.

9. The president and his party, and the corporate media have spent more time and energy silencing and excluded the advocates of single payer health care, mostly the president’s own supporters, than they have fighting blue dogs and Republicans.

But no matter how diligently the spokespeople for single payer are excluded from media coverage and invitations to Obama’s policy forums and round tables, no matter how many times the White House cuts their questions from transcripts and video of public events, the calls, emails and letters keep pouring into Congress and the White House demanding the creation of a publicly funded, everybody-in-nobody-out system, a Medicare-for-All kind of single payer health care plan.

10. Despite the president’s own admission that only a single payer health care system will deliver what Americans want, he and the leaders of his party insist that Medicare For All, HR 676, us utterly off the table.

Before he became a presidential candidate, Barack Obama identified himself as a proponent of a single payer health care system. All we had to do, he told us, was elect a Democratic congress and senate, and a different president. Now that this has been done, he insists that “change” is just not possible, and we have to settle for less. The president continues to admit that only a single payer health care system will cover everybody, but insists that America just can’t handle that much change.

The truth is that Barack Obama campaigned as the candidate of change, and a health care system that covers everybody from day one with no exceptions is what people imagined they voted for when they swept him and an overwhelming number of Democrats into office.

A single payer Medicare-For-All system will eliminate 500,000 insurance company jobs and replace them with 3.2 million new jobs in health care for a net gain of 2.6 million new jobs according to a study by the National Nurses Organization. That’s as many jobs as the US economy lost in all of 2007. Single payer will create hundreds of billions in annual wages and local and state tax revenues for cash strapped cities and towns. It will lift the shadow of bankruptcy for medical reasons from two thirds of a million American families yearly. It’s what we deserve.

It’s what we voted for, and we won’t stop demanding it.

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Bruce Dixon is based in Atlanta GA and is managing editor at Black Agenda Report. He can be reached at bruce.dixon@blackagendareport.com.

http://www.blackagendareport.com/?q=content/top-ten-ways-tell-your-president-his-party-arent-fighting-health-care-everybody

By Allan S. Brett, M.D.
New England Journal of Medicine
Volume 361:440-441 July 30, 2009 Number 5

Amid all the rhetoric about health care reform, one claim has emerged as a trump card designed to preserve the current patchwork of private and public insurance and to stop discussion of a government-sponsored single-payer system in its tracks: the claim that single-payer health care — a Canadian-style Medicare-for-all system — is antithetical to “American values.” The idea that American values dictate a particular approach to health care reform is often stated explicitly, and it is implicit in the generalization that “Americans want” a particular system. The underlying premise is that an identifiable set of American values point incontrovertibly to a health care system anchored by the private insurance industry. Remarkably, this premise has received very little scrutiny.

Two related assumptions are buried in the language of “American values.” The first is that there are archetypical Americans — that if we know someone fits the category “American,” it should be possible to predict his or her general worldview accurately. However, we have good reason to doubt that assumption. In nearly all respects — ethnically, culturally, religiously, politically, and socioeconomically — Americans are increasingly diverse. The recent presidential campaign provides evidence that a monolithic conception of what it means to be “American” is problematic and outdated: those who championed the idea of “real” Americans (as distinct from Americans who are somehow less representative of American ideals) were precisely those whose candidate lost the election.

The second assumption is that Americans’ personal values predictably translate into certain orga nizational structures for the financing and provision of health care — and that a single-payer system is not among them. Exactly what might those values be? Are they self-regarding values directed toward maximizing individual well-being and potential? Or other-regarding values such as altruism or concern for community? Clear ly, most people — regardless of political, ethnic, or cultural identity — regard both sets of values as important in varying proportions; nothing precludes a single-payer system as one possible means of realizing a blend of these values.

The notion that American values militate against a single-payer system is advanced not only by advocates of preserving the status quo or making incremental changes but also by some who propose major reforms that nibble around the edges of a single-payer system. For example, Ezekiel Emanuel — now a special adviser on the Obama administration’s health care team — has proposed universal health insurance funded by a value-added tax on sold goods and services; all citizens would receive government-issued vouchers to purchase health insurance from private insurance companies. According to Emanuel, such a plan “coheres with core American values: individualism and equality of opportunity.” He argues that equality of opportunity dictates universal coverage and government funding, but individualism dictates preservation of the private insurance system: “Americans clamor . . . for the chance to choose. . . . We want to choose our insurance plans, our hospitals, our doctors.”¹

The theme of “choice” also surfaces in the writing of Tom Daschle, President Barack Obama’s initial pick for secretary of health and human services. In his book Critical, Daschle proposes universal coverage delivered through a private-public hybrid plan. He all but admits that a single-payer system i s the best solution but abandons the idea because it is “politically problematic” and because “compared to residents of [European countries], Americans are more supportive of choice and suspicious of government.”²

Suppose that “freedom to choose” is indeed the paramount American value relevant to health care. For many people, it would surely imply choice of physician, hospital, or clinic. For such choice, a single-payer system beats the competition hands down. Incremental reforms preserving the private insurance industry and employer-based insurance would probably perpetuate the restricted choice of health care providers that many Americans already encounter: private plans typically limit access to certain physicians or hospitals, and physicians often refuse to accept certain plans. In contrast, single-payer proposals eliminate those restrictions.

Another possible meaning of “choice” is the freedom to choose from an array of private insurance companies. Here it is important to acknowledge that insurance is only a means for collecting and disbursing health care funds — not an end in itself. The key question is therefore whether private insurance is superior to single-payer insurance in ach ieving the desired end of efficient, cost-effective health care. Here, too, the single-payer system would probably prevail. Because administrative costs are consistently lower in single-payer systems than in private-based systems, more of the health care budget goes directly to patient care (and less to administration) in single-payer systems. Thus, American s have been misled by the rhetoric about choice. In contrast with the single-payer option, a system with multiple private insurers would continue to restrict one dimension of choice (selection of physicians) and perpetuate a choice most people would consider irrational (wasteful spending on administrative overhead).

A third dimension of choice is the freedom to choose whatever test or treatment a patient wants. This choice is system-neutral, pointing to neither single-payer nor alternative systems. Any reform initiative must control spending; unproven or unnecessary medical interventions should not be available in any system.

A closely related rhetorical device — the idea that Americans or American values are “unique” — also deserves attention. For example, Emanuel describes individualism and equality of opportunity as “uniquely American.”1 Senator Max Baucus (D-MT), chairman of the Senate Finance Committee, asserts that a public-private hybrid is essential because it is a “uniquely American solution.”³ Others describe rugged individualism as a “uniquely American” value that makes us “reluctant to provide our tax dollars to support someone else’s health care.”⁴ Such defiant-sounding assertions imply that “uniqueness” is a matter of pride and an end in itself. But these generalizations are impossible to prove, a distraction in the debate, and ultimately irrelevant. What is relevant is whether a solution works, not whether it is unique. Indeed, the aspect of the current U.S. system that is truly unique among developed countries is its failure to cover everyone — hardly something to brag about.

In their book Benchmarks of Fairness for Health Care Reform, Norman Daniels and colleagues reject these “ungenerous” views of our values, arguing that past failures to reform health care are better explained by the influence of interest groups whose wealth and power are threatened by reform.⁵ The authors propose that fair equality of opportunity is a more promising and relevant American value. Opinion polls support this proposal: in multiple surveys of randomly selected Americans during the past decade, more than 60% of respondents have favored government-guaranteed health care for all. Although these responses don’t necessarily specify a single-payer system as the only model for government-guaranteed insurance, they surely do not exclude it.

Policymakers debating health care reform should stop hiding behind the smoke screen of “American values.” Discussions dominated by references to uniquely American individualism, uniquely American solutions, or narrowly defined conceptions of choice tell us more about the political and economic interests of the discussants than about the interests of the Americans they claim to represent. In an increasingly diverse country that has a widening gap between rich and poor, a more promising approach is to start with the questions that matter to everyone: Will the system care for us when we’re sick and help prevent illness when we’re well? Will we have access to medical care throughout our lives without risking fi nancial ruin? Will we be able to navigate the system easily, without jumping through unnecessary hoops or encountering excessive red tape? Will health care spending be managed wisely? Health care reformers owe Americans a system that best addresses these questions — not one that merely pays lip service to ill-defined “American values.”

No potential conflict of interest relevant to this article was reported.

Source Information: From the University of South Carolina School of Medicine, Columbia.

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References

1. Emanuel EJ. Healthcare, guaranteed: a simple, secure solution for America. New York: PublicAffairs, 2008:12-6.

2. Daschle T. Critical: what we can do about the health-care crisis. New York: Thomas Dunne Books, 2008:144, 204.

3. Medical News Today. Sen. Baucus hopes to introduce comprehensive health reform legislation this summer. March 5, 2009. (Accessed July 10, 2009, at http://www.medicalnewstoday.com/articles/141193.php.)

4. Garson A Jr, Engelhard CL. Health care half-truths: too many myths, not enough reality. Lanham, MD: Rowman & Littlefield, 2007:131-2.

5. Daniels N, Light DW, Caplan RL. Benchmarks of fairness for health care reform. New York: Oxford University Press, 1996:15-22.
http://content.nejm.org/cgi/content/full/361/5/440