PNHP

Dr. Steffie Woolhandler on the Presidential Candidates & Single-Payer in the 2008 Elections

Dr. Steffie Woolhandler on the Presidential Candidates & Single-Payer in the 2008 Elections

Dr. Steffie Woolhandler, co-founder of Physicians for National Health Program (PNHP), a group of over 15,000 physicians nationwide who support a single-payer health care system, spoke on June 26 in Chicago at the PNHP offices. She spoke about the presidential candidates’ health plans and single-payer in the 2008 elections. She is an associate professor at Harvard Medical School and an internist at Cambridge Hospital in Cambridge, Mass. The transcript below was prepared by Elizabeth Lalasz of Chicago; it was subsequently edited by Dr. Woolhandler.

I’ve been asked to make some comments on the upcoming Presidential elections and developing a strategy around them. I am an expert in health policy, not on political strategy. But I want to talk a little about where I see us going in the single-payer movement within the broader political context.

I am paradoxically optimistic about the political situation right now. I say paradoxically because if we look at the actual health policy proposals of Obama and McCain, they are not good.

Let’s start with McCain. He has said that he is going to continue most of the proposals of the Bush Administration, and perhaps accelerate the privatization of Medicare. He does not use the word privatization – but he’s been very clear that he is going to push for more “competition” and “choice” within Medicare, euphemisms for privatization.

He’s also very big on consumer-directed health care – bare-bones health plans with big co-payments and deductibles – as a way to save money. He has put forward a fairly desultory proposal about refundable tax credits, after many months during which no concrete proposals for health reform appeared on his web site. His come-lately proposal would offer a refundable tax credit of $2,500 for an individual, $5,000 for a family, far too little to afford adequate coverage.

What he doesn’t say on his web site is how he would fund the tax credit. So we are left wondering. If McCain goes with a Bush-style plan – and many pundits talk as if that is the case – then the tax credits would be funded by caps on, or even eliminating the tax-deductibility of employer-based insurance. This would cause a very sharp contraction in employer-based coverage.

McCain’s proposes what I would call the “voucherization” of health care; families would get a fixed tax credit (or a fixed amount of tax deductibility of an employer-sponsored plan) and above that there would be no further direct or indirect government subsidies for health care. So, it is essentially turning the current open-ended government tax subsidy into a limited government voucher. In essence, this is akin to a switch from a defined benefit system to a defined contribution system.

For those not familiar with this concept, let’s back up a little bit and discuss pensions. Retirees used to get pensions with a defined benefit, say 60 percent of your salary for as long as you lived. But few of us will get such pensions in the future. Nowadays, we get something called a defined contribution, at my institution, the employer puts 6 percent of my salary into a retirement plan. It turns out 6 percent of my salary summed up over 30 working years is a whole lot less money than what you would need to generate 60 percent of my salary for the rest of my life. So, the new pension arrangements, like the Bush/McCain health proposals, are actually a massive cutback disguised as a shift from a defined benefit to a defined contribution.

Needless to say, the concept of switching from defined benefit to defined contribution has been very popular with Republican leaders. There’s been an effort to move Medicare in that direction (under the moniker “premium support”) where the federal government would pay $6,000-$8,000 toward each senior’s coverage, but would not guarantee the full future costs of care. McCain’s plan seems to represent a similar effort within the commercial (non-elderly) health insurance market to push people into defined contribution rather than defined benefit arrangements.

We could spend more time on the many other problems with McCain’s proposals, but to be honest I don’t think it’s worth focusing too much on its details because it doesn’t appear that even McCain is serious about his health plan. He was under pressure to come up with something, and hence his staff produced a plan. Like President Bush, I doubt that McCain has any intention of actually pursuing his tax credit plan.

As for Obama his health proposal is not a universal health care plan; in fact, he doesn’t even claim that it is. He would greatly expand Medicaid and Medicaid-like programs. Medicaid expansion is of course, better than no Medicaid expansion; those of us who work in the public sector know that. But we also know that Medicaid and Medicaid-like expansions have been tried over and over for the last thirty years, and the number of uninsured and underinsured has continued to increase.

Immediately after such Medicaid expansions, we usually see a small, and short-lived drop in the number of uninsured. We are seeing that in Massachusetts right now. As long as we keep pumping money into Medicaid or similar programs, we can push down the number of uninsured a little bit. But that’s not a viable, long-term strategy because it’s not affordable. Obama does propose devoting significant new money to the expansion of Medicaid and S-CHIP (State Children’s Health Insurance Program), but, as in the past, such expansions yield small and temporary improvement.

Obama is also talking about an employer mandate – requiring employers to cover their workers – but has provided few details about exactly what would be required. Even in a wealthy and liberal state like Massachusetts, employers were able to block the implementation of an effective employer mandate (even though a law requiring employers to cover their workers was passed in 1988).

In fact the only mandate Obama is clear about is a mandate that parents be required to buy health insurance for their children. But this would leave tens of millions of American adults uninsured if the Obama plan goes though as he proposes it.

So, my optimism is not based on Obama’s proposal and it’s certainly not based on McCain’s proposal. My optimism is based on something taught to me by a nurse in the Boston-area and a longtime single-payer activist. She used to say, “People say politics is the art of the possible, but they are wrong. Politics is the art of creating the possible. And what is possible is about what people believe is possible.”

I believe the biggest impediment to our work over the last decade has not been the lack of a good program, because we know what a good single-payer program would look like. We have H.R. 676. We can look to Canada and places in northwestern Europe. So we have good models and we have a good program.

The problem is the lack of hope – the lack of a sense of possibility. People hate the health insurance system and they know things need to change. But people don’t believe things can change.

So, what we really need is an infusion of hope. Even if Obama can’t deliver on his proposals, when he raises peoples’ expectation they begin to believe that change is possible, and that’s a real force for change.

In some ways President Kennedy provides an example of this. He was not all that liberal, or effective as a leader of social change. But his election let people think that change was possible, and helped ignite the social movements of the Sixties. It gave new impetus to the Civil Rights movement, and certainly helped ignite the social currents that gave rise to the women’s and anti-war movements. His election raised people’s sense of possibility and that force pushed social change further, and faster John Kennedy envisioned.

I think we’re at a similar moment now. Many people view Obama as someone new and exciting; he brings a sense of possibility and optimism we have not seen in this country’s political culture for a long time.

The question we need to address is what do single-payer advocates do now? How do we use this opportunity to open up a thoroughgoing health reform debate, and pave the way for progress. Now, even more than in periods when reform was not really on the agenda, we need to articulate the single-payer message. As Obama and Congress take up the health reform debate early in the next administration, there must be a clear-eyed vision for reform that can work on the table. We must spread the word that the single-payer alternative has wide support, and a track record of success. While the alternatives are merely replays of failed proposals from the past.

Confronting the cost of health care

By Amy Kotlarz
Catholic Courier
July 1, 2008

An estimated 18,000 people in the United States die unnecessarily each year because they have no health insurance, according to the nonprofit Institute of Medicine of the National Academies.

Robin Salerno is trying her best to not become one of them. But Salerno has adrenal cancer, no insurance and few options.

A resident of Wolcott, Wayne County, she works six days a week at a local diner, earning about $17,000 a year. That’s too much to qualify for Medicaid or Family Health Plus.

Salerno might qualify for Healthy NY, an insurance program for small businesses and workers whose jobs don’t offer insurance, but services for her cancer might not be covered for a year.

“If I wait a year, I might not be around,” said Salerno, 50.

The cheapest private-market plan in Wayne County would cost her $767 a month — half of her monthly income.

Instead, she has been paying out-of-pocket for medications, doctor’s visits and such tests as MRIs and CT scans. Portions of her tests have been paid by the U.S. Department of Health and Human Services’ Hill Burton funds program for free or low-cost care — and by financial help from her mother.

Salerno is not alone in her struggle with the U.S. health-care system. Grassroots groups across the state and nation have been working to reform the health-care system, which some say is becoming increasingly unaffordable due to rising health costs.

This year’s presidential campaign also has fueled the debate, with both presumptive presidential nominees drafting health-care reform plans, details of which are available on their respective Web sites.

Reform proposals

Presumptive Republican nominee John McCain’s plan would allow consumers to direct how their health-care dollars would be used, create a guaranteed coverage plan for the uninsured and sick, create a tax credit to offset the cost of insurance, and expand the benefits of health-savings accounts.

Presumptive Democratic nominee Barack Obama’s plan would create a national health plan available to all and funded in part by employers who do not offer health insurance. He would also implement a health-insurance exchange that would help individuals to buy private insurance plans.

New York state also took up the issue in July 2007 when its departments of health and insurance formed the Partnership for Coverage panel to study obstacles to health coverage. According to its Web site at www.partnership4coverage.ny.gov, the panel’s ultimate goal is to develop, evaluate and recommend proposals for achieving universal coverage by building on existing programs.

The panel led hearings across the state during the fall of 2007.

“While many promoted expansion of public programs, others cautioned about the cost of such expansions, the impact on the state budget and the public tax burden and concern about replacing private dollars with public dollars,” stated the panel’s May 28 report to Gov. David Paterson, summarizing the findings of its hearings.

Escalating costs

The report notes that the Washington, D.C.-based Urban Institute was hired in December as a consultant to develop and study several models of proposals for universal coverage. As part of their work with the Partnership for Coverage, the state departments of health and insurance also are considering ways to contain health-care costs.

The state Catholic conference has also recommended this approach.

“Attempts to address the issue of the uninsured cannot succeed unless and until we examine the causes for the high costs of health services,” said Ron Guglielmo, director for health care for the New York State Catholic Conference, during testimony to the state panel.

According to the Kaiser Family Foundation, U.S. health-care spending grew 6.7 percent in 2006 to about $7,026 per resident, accounting for 16 percent of the nation’s gross domestic product. Per-capita health-care spending has more than doubled since 1990. And, according to the Centers for Medicare and Medicaid Services, health-care spending is projected to rise to more than $12,750 per person by 2016.

Longer life spans, more intensive treatment of chronic illness, increasingly expensive prescription drugs and technology, an aging population and higher administrative costs are driving these cost increases, the foundation said.

Fidelis Care, the New York state Catholic bishops’ health-insurance plan, has provided thousands of New Yorkers with health coverage through Child Health Plus, Family Health Plus and Medicaid programs. Yet millions of state residents aren’t eligible for these programs and still cannot afford private insurance, acknowledged Mark Lane, Fidelis Care president and CEO.

“There are 3 million people in New York state who can’t afford (insurance) or who have decided not to have it,” Lane said. “For the vast majority, affordability is an issue.”

No easy answers

Lane said there are several ways to make health insurance more affordable, but that each poses its own combination of benefits and drawbacks. Among the possible trade-offs inherent in the various plans are reducing benefits to cover more people; capping medical costs and freezing providers’ reimbursement rates; mandating that everyone obtain insurance; and rationing care to limit high-cost or high-risk procedures.

“There are no easy solutions,” he said.

The high administrative cost of health insurance is the target of several reform proposals. Dr. Leon N. Zoghlin of Hilton, a retired family-practice physician who volunteers at the St. Joseph’s Neighborhood Center on South Avenue in Rochester, contends that insurance-company bureaucracy and profit margins have led to higher costs for medical care.

Zoghlin is a member of Physicians for a National Health Program, which advocates a single-payer system in which the government or a single nonprofit entity would pay private doctors and hospitals to deliver health care.

Critics of single-payer systems charge that such a system would usher in socialized medicine, but Zoghlin notes that single-payer health proposals do not call for the government to own all the resources and means for production and distribution, as it does with respect to the U.S. Veteran’s Administration.

“We would funnel all our funds through the government, but care would be delivered by private sources or community not-for-profit sources, like hospitals,” Zoghlin said.

Zoghlin points to the single-payer insurance systems of many other developed countries and the lower administrative costs of Medicare, which is a single-payer system for the elderly and disabled, as compared to the costs of private insurance. He said he believes businesses are warming to a single-payer system because of spiraling health-insurance costs, and that doctors increasingly support the idea due to frustration with insurance-company denials and low reimbursements.

Yet some worry that proposals calling for increased government control over health care would lead to a loss of quality, a rationing of care, longer wait times or other negative consequences.

“I’m fearful that if the government takes over the health industry, then that would be the end of it,” said Dick Hastings of Perinton, who attended a May 8 talk in Rochester on health-care reform.

For its part, the Partnership for Coverage panel said advocates of a single-payer system need to provide more specifics on how such a model would operate in New York state.

Insurers told the panel that the state’s restrictive regulations on health-maintenance organizations and other mandates have made coverage plans for small businesses and individuals unaffordable. Empire and Excellus Blue Cross Blue Shield, for example, presented proposals to change state regulations to allow HMOs to merge the markets for individuals and small businesses, potentially decreasing the cost of such plans, and to add lower-priced consumer-directed plans.

Standards-based approaches

Rather than endorsing specific plans for reform, such organizations as the Catholic Health Association and the American Cancer Society are advocating standards for reform. Not surprisingly, the Catholic Health Association frames the debate in moral terms.

“This debate really speaks to our values and national priorities,” said Jeff Tieman, CHA’s senior director of health-reform initiatives, during a May 8 talk as part of the Downtown Community Forum at St. Mary Parish in Rochester.

Tieman delivered similar talks to the board and management of St. Joseph’s Hospital in Elmira May 8 and to the Catholic Media Convention in Toronto, Canada, May 29.

Tieman noted that the consequences of allowing large numbers of people to remain uninsured or underinsured include delayed treatment; expensive and inappropriate treatment in emergency rooms; and emotional and economic tolls on families. About half of bankruptcies are due to medical debt, he said, and 80 percent of the uninsured are members of working families.

CHA asserts that health care should be available and accessible to all; oriented toward health and prevention; sufficiently and fairly financed; transparent and driven by consensus; patient centered; and safe, effective and designed to deliver quality.

“This is a matter of community health and well-being,” Tieman said May 29. “We don’t want to be surrounded by sick people. We want to be surrounded by people who are healthy.”

Hillary Clarke, regional advocacy director and federal-issues manager for the Eastern Division of the American Cancer Society, said her agency’s standards for evaluating health-care proposals are: adequacy of coverage, availability based on medical history and inclusive eligibility standards, affordability for those with limited means and administrative simplicity. The society was one of many organizations that presented its agenda for health-care reform to the Partnership for Coverage panel.

In the case of cancer and other debilitating diseases, Clarke noted that even those who have insurance may struggle to afford coverage or lose their coverage if they are unable to work due to treatments.

“Any of us is one bad diagnosis away from a bad financial disaster,” Clarke said.

Some clergy and health representatives from the Greater Rochester Community of Churches began developing their own standards for health-care reform during a June 10 breakfast at Colgate Rochester Crozier Divinity School. The breakfast was sponsored by the Healthcare Education Project, which is a collaboration of Greater New York Hospital Association and the 1199 SEIU Healthcare Workers East, a union of health-care workers.

One advocate suggested the group work together on systemic change.

“I believe we make no headway in improving health care by blaming or accusing anybody or any health-care institution,” observed Sister of St. Joseph Christine Wagner, director of St. Joseph’s Neighborhood Center on South Avenue in Rochester.

Sister Wagner told of a physician from the Democratic Republic of Congo who toured the center. He had been tasked with rebuilding his country’s health-care system after it was destroyed by civil war.

His perspective helped her reconsider her ministry, she said.

“We are blessed with the resources we have,” she said. “All we need to do is put these resources together.”

http://www.catholic-courier.com

Copyright (c) 2008 Rochester Catholic Press Association, Inc. May not be published, broadcast, rewritten or otherwise distributed, including but not limited to such means as framing or any other digital copying or distribution method, in whole or in part without the publisher’s consent.

Response to TNR’s Jonathan Cohn

Disputations: Is Single-Payer Health Care The Best Option?

The problem with split-the-difference incremental reform.

by Don McCanne
The New Republic
July 16, 2008

The enthusiasm for the model of reform described by Jacob Hacker and endorsed by the Health Care for America Now (HCAN) coalition, which Jonathan Cohn wrote about in his recent New Republic piece “Single-Minded,” is understandable. It is a model that attempts to align policy with politics, allegedly meeting the previously unattainable threshold of feasibility. But is it feasible, and will it even work?

Anyone who really believes in this model understands that the private insurance plans would have to be very tightly regulated to reduce the profound deficiencies in our current insurance markets. The current private insurance business model depends on selling the insurers’ products to the large numbers of us who are healthy, especially the healthy workforce and their healthy families, while avoiding the need to contribute to the risk pools that cover those who have greater health care needs. Those costs are largely passed on to taxpayers through government programs.

Other nations that use private plans require effective pooling between plans through various regulatory mechanisms, reducing the problem of adverse selection and ensuring that premiums or taxes are adequate to pay for the care for those with greater needs. Even if the pools are nominally segregated, they function more like a universal risk pool through mechanisms such as risk adjustment and post-claims inter-insurance transfers.

The United States has a unique problem that would make it much more difficult to require private insurers to participate in a quasi-universal risk pool. On a per capita basis, we pay far more for health care than do other nations. Average-income individuals in other nations that use private plans can still afford premiums (or their tax equivalents). In those countries, only low-income individuals require some form of government subsidy for their care.

Compare that with the United States. For healthy risk pools, such as those of employer-sponsored plans, premiums are no longer affordable for average-income individuals and families, whether paid directly by the insured, or nominally by the employer. Imagine a tightly regulated insurance market that ended adverse selection and required benefits at a level that would prevent financial hardship for those with health care needs. The private insurers would find it absolutely impossible to provide us with compliant products that had affordable premiums.

Because of our very high costs, we must accept the fact that the insurance function is no longer simply a transfer from the many who are healthy to the fewer with health care needs, but it now must also include a partial transfer from the wealthy to middle- and lower-income individuals with needs. There is no alternative to this wealth transfer, and that alone creates doubt as to whether a model of highly regulated private plans is politically feasible.

We have to get over the idea that financing should be through premiums set by the actuarial value of the benefits in the insurance products. Those premiums are no longer affordable for most of us, and the complexities of income-related adjustments, whether through premium adjustments or tax credits, create an administrative nightmare. It is time that we separate the financing of the universal risk pool from the health care benefit package. The tax system provides us with the most equitable and efficient method of financing our global health care costs.

Perhaps a more compelling reason that the private insurance model no longer works is that it is very ineffective in slowing the increases in health care costs, and everyone agrees that affordability is now a major problem. Most of the current political cost-saving proposals would have very little impact on total costs. We need to address the true major cost drivers: the profound administrative excesses, the lack of an adequate primary care infrastructure, the waste of non-beneficial high-tech excesses, and the lack of a rational system of health care pricing. Even in a regulated environment, it would be very difficult for a multitude of private insurers and public programs to have much impact on these excess costs. Most economists agree that a monopsony, or single purchaser of health care products and services, would be most effective in extracting value through a negotiated realignment of incentives in our health care purchasing.

This debate that is taking place within the progressive community is missing the center of the feasibility dispute. It is implied that the Hacker/HCAN progressive model would be just fine if the single payer advocates would come to their senses and join in. It ignores the fact that this model is simply not politically feasible: it loses the support of market enthusiasts because of its dependency on tight regulatory control, intrusion by a government insurance program, and the necessity of a massive infusion of tax funds.

If you are going to accept that those changes are necessary to provide adequate coverage for everyone, then you might as well go ahead and establish a much more efficient and effective single payer national health program. Some may argue that explicit calls for income transfer and bureaucratic control of spending are what limit the political feasibility of the single payer model, but the private plans/public option model would have to incorporate the same principles, and their advocates should be very frank about that upfront.

So, the bottom line? We need reform that provides everyone the health care that they need, without financial barriers that would impede access. We can attempt to maneuver around the ubiquitous mines and trap doors of the political common ground of Hacker/HCAN, and still end up short if we survive. Or we can go straight to a proven model that would accomplish all of our financing goals–a single payer national health program.

For the full article:
http://tnr.com/politics/story.html?id=7aa401b5-f1f4-4564-921c-00f97b917605%20

Comment:

By Don McCanne, MD

The real debate over health care reform today centers over one fundamental choice. Are we going to continue to try to finance health care through private plans competing in the marketplace, a guarantee that access and equity problems would only grow worse, or are we going to use our own government resources to fix our financing system so that it works for everyone?

This shouldn’t even be a debate. Financial hardship, physical suffering and even death will increase without significant government intervention.

Unfortunately, a much less important debate has erupted within the community of those supporting a government role in ensuring that everyone has affordable access to all necessary health care. That debate is over whether or not private health plans should play a role in a reformed health care financing system.

Eliminating a socialized-medicine national health service from the list of options, that leaves us with two basic choices. We can either radically transform the private health plans into a system of social insurance, or we can replace the plans with a Medicare-like single payer national health program. Either would work, but the trade-offs are significant.

Systems using private plans are more expensive, largely because of greater administrative complexity. Equity is more difficult to achieve in a multi-payer system. A system of universal risk pooling would have to be superimposed on the private plans, making us wonder why we would even want to keep them since they would no longer be providing their insurance function of transferring risk.

Today, affordability is a concern for everyone. Health care will never again be affordable for all of us unless we adopt structural changes within our health care delivery system. As stated in the TNR article, “We need to address the true major cost drivers: the profound administrative excesses, the lack of an adequate primary care infrastructure, the waste of non-beneficial high-tech excesses, and the lack of a rational system of health care pricing.” Realigning incentives to accomplish these goals would be a relatively straightforward task for a single payer government monopsony. In contrast, a market of competing private plans would not have the power of a monopsony and would have to rely on the government to achieve these same goals.

Those supporting the private plan/public option model need to be explicit in describing their model, beginning with simple concepts such as how they would prevent adverse selection in the public option. If we are going to have an equitable and effective health care financing system for all of us, then their task of radically transforming the private insurance industry so that it would actually work is far greater than our task of improving Medicare and then providing it to everyone. Let’s hear how they would do it.

Dr. Steffie Woolhandler on the Presidential Candidates & Single-Payer in the 2008 Elections

Dr. Steffie Woolhandler, co-founder of Physicians for National Health Program (PNHP), a group of over 15,000 physicians nationwide who support a single-payer health care system, spoke on June 26 in Chicago at the PNHP offices. She spoke about the presidential candidates’ health plans and single-payer in the 2008 elections. She is an associate professor at Harvard Medical School and an internist at Cambridge Hospital in Cambridge, Mass. The transcript below was prepared by Elizabeth Lalasz of Chicago; it was subsequently edited by Dr. Woolhandler.

I’ve been asked to make some comments on the upcoming Presidential elections and developing a strategy around them. I am an expert in health policy, not on political strategy. But I want to talk a little about where I see us going in the single-payer movement within the broader political context.

I am paradoxically optimistic about the political situation right now. I say paradoxically because if we look at the actual health policy proposals of Obama and McCain, they are not good.

Let’s start with McCain. He has said that he is going to continue most of the proposals of the Bush Administration, and perhaps accelerate the privatization of Medicare. He does not use the word privatization – but he’s been very clear that he is going to push for more “competition” and “choice” within Medicare, euphemisms for privatization.

He’s also very big on consumer-directed health care – bare-bones health plans with big co-payments and deductibles – as a way to save money. He has put forward a fairly desultory proposal about refundable tax credits, after many months during which no concrete proposals for health reform appeared on his web site. His come-lately proposal would offer a refundable tax credit of $2,500 for an individual, $5,000 for a family, far too little to afford adequate coverage.

What he doesn’t say on his web site is how he would fund the tax credit. So we are left wondering. If McCain goes with a Bush-style plan – and many pundits talk as if that is the case – then the tax credits would be funded by caps on, or even eliminating the tax-deductibility of employer-based insurance. This would cause a very sharp contraction in employer-based coverage.

McCain’s proposes what I would call the “voucherization” of health care; families would get a fixed tax credit (or a fixed amount of tax deductibility of an employer-sponsored plan) and above that there would be no further direct or indirect government subsidies for health care. So, it is essentially turning the current open-ended government tax subsidy into a limited government voucher. In essence, this is akin to a switch from a defined benefit system to a defined contribution system.

For those not familiar with this concept, let’s back up a little bit and discuss pensions. Retirees used to get pensions with a defined benefit, say 60 percent of your salary for as long as you lived. But few of us will get such pensions in the future. Nowadays, we get something called a defined contribution, at my institution, the employer puts 6 percent of my salary into a retirement plan. It turns out 6 percent of my salary summed up over 30 working years is a whole lot less money than what you would need to generate 60 percent of my salary for the rest of my life. So, the new pension arrangements, like the Bush/McCain health proposals, are actually a massive cutback disguised as a shift from a defined benefit to a defined contribution.

Needless to say, the concept of switching from defined benefit to defined contribution has been very popular with Republican leaders. There’s been an effort to move Medicare in that direction (under the moniker “premium support”) where the federal government would pay $6,000-$8,000 toward each senior’s coverage, but would not guarantee the full future costs of care. McCain’s plan seems to represent a similar effort within the commercial (non-elderly) health insurance market to push people into defined contribution rather than defined benefit arrangements.

We could spend more time on the many other problems with McCain’s proposals, but to be honest I don’t think it’s worth focusing too much on its details because it doesn’t appear that even McCain is serious about his health plan. He was under pressure to come up with something, and hence his staff produced a plan. Like President Bush, I doubt that McCain has any intention of actually pursuing his tax credit plan.

As for Obama his health proposal is not a universal health care plan; in fact, he doesn’t even claim that it is. He would greatly expand Medicaid and Medicaid-like programs. Medicaid expansion is of course, better than no Medicaid expansion; those of us who work in the public sector know that. But we also know that Medicaid and Medicaid-like expansions have been tried over and over for the last thirty years, and the number of uninsured and underinsured has continued to increase.

Immediately after such Medicaid expansions, we usually see a small, and short-lived drop in the number of uninsured. We are seeing that in Massachusetts right now. As long as we keep pumping money into Medicaid or similar programs, we can push down the number of uninsured a little bit. But that’s not a viable, long-term strategy because it’s not affordable. Obama does propose devoting significant new money to the expansion of Medicaid and S-CHIP (State Children’s Health Insurance Program), but, as in the past, such expansions yield small and temporary improvement.

Obama is also talking about an employer mandate – requiring employers to cover their workers – but has provided few details about exactly what would be required. Even in a wealthy and liberal state like Massachusetts, employers were able to block the implementation of an effective employer mandate (even though a law requiring employers to cover their workers was passed in 1988).

In fact the only mandate Obama is clear about is a mandate that parents be required to buy health insurance for their children. But this would leave tens of millions of American adults uninsured if the Obama plan goes though as he proposes it.

So, my optimism is not based on Obama’s proposal and it’s certainly not based on McCain’s proposal. My optimism is based on something taught to me by a nurse in the Boston-area and a longtime single-payer activist. She used to say, “People say politics is the art of the possible, but they are wrong. Politics is the art of creating the possible. And what is possible is about what people believe is possible.”

I believe the biggest impediment to our work over the last decade has not been the lack of a good program, because we know what a good single-payer program would look like. We have H.R. 676. We can look to Canada and places in northwestern Europe. So we have good models and we have a good program.

The problem is the lack of hope – the lack of a sense of possibility. People hate the health insurance system and they know things need to change. But people don’t believe things can change.

So, what we really need is an infusion of hope. Even if Obama can’t deliver on his proposals, when he raises peoples’ expectation they begin to believe that change is possible, and that’s a real force for change.

In some ways President Kennedy provides an example of this. He was not all that liberal, or effective as a leader of social change. But his election let people think that change was possible, and helped ignite the social movements of the Sixties. It gave new impetus to the Civil Rights movement, and certainly helped ignite the social currents that gave rise to the women’s and anti-war movements. His election raised people’s sense of possibility and that force pushed social change further, and faster John Kennedy envisioned.

I think we’re at a similar moment now. Many people view Obama as someone new and exciting; he brings a sense of possibility and optimism we have not seen in this country’s political culture for a long time.

The question we need to address is what do single-payer advocates do now? How do we use this opportunity to open up a thoroughgoing health reform debate, and pave the way for progress. Now, even more than in periods when reform was not really on the agenda, we need to articulate the single-payer message. As Obama and Congress take up the health reform debate early in the next administration, there must be a clear-eyed vision for reform that can work on the table. We must spread the word that the single-payer alternative has wide support, and a track record of success. While the alternatives are merely replays of failed proposals from the past.

National health insurance makes the green journal

National Health Insurance: Could It Work in the US?

By James E. Dalen, MD, MPH, Joseph S. Alpert, MD
The American Journal of Medicine
July 2008
National health insurance covers the entire population of many European countries at a much lower cost than US health care. Could such a system of national health insurance work in the US? We already have such a system ā€” it is called Medicare, and it has worked very well for more than 40 years! Medicare pays the private sector to deliver quality health care to more than 44 million Americans. Those who stick with traditional Medicare have free choice of physicians and hospitals. Nearly every US physician and nearly every hospital in the US has elected to participate in Medicare.
In a 2003 Pew poll, 67% favored government guaranteed national health insurance even if meant higher taxes, and a 2007 New York Times/CBS poll reported that 64% stated that the Federal government should guarantee health insurance for all Americans. Maybe the American people are ahead of their legislators!
http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934308002465.pdf

Reading a message in support of a Medicare-like national health insurance program is certainly not a new experience for single payer advocates. What is astonishing is that this was published in “the green journal,” The American Journal of Medicine, one of the most prestigious medical publications in this nation. Furthermore, it was coauthored by the Editor-in-Chief, Joseph Alpert.
National health insurance is no longer a fringe concept. The American people have made it mainstream. It has become an imperative. We now need to elect legislators who understand that.

qotd: National health insurance makes the green journal

National Health Insurance: Could It Work in the US?

By James E. Dalen, MD, MPH, Joseph S. Alpert, MD
The American Journal of Medicine
July 2008

National health insurance covers the entire population of many European countries at a much lower cost than US health care. Could such a system of national health insurance work in the US? We already have such a system — it is called Medicare, and it has worked very well for more than 40 years! Medicare pays the private sector to deliver quality health care to more than 44 million Americans. Those who stick with traditional Medicare have free choice of physicians and hospitals. Nearly every US physician and nearly every hospital in the US has elected to participate in Medicare.

In a 2003 Pew poll, 67% favored government guaranteed national health insurance even if meant higher taxes, and a 2007 New York Times/CBS poll reported that 64% stated that the Federal government should guarantee health insurance for all Americans. Maybe the American people are ahead of their legislators!

http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934308002465.pdf

Comment:

By Don McCanne, MD

Reading a message in support of a Medicare-like national health insurance program is certainly not a new experience for single payer advocates. What is astonishing is that this was published in “the green journal,” The American Journal of Medicine, one of the most prestigious medical publications in this nation. Furthermore, it was coauthored by the Editor-in-Chief, Joseph Alpert.

National health insurance is no longer a fringe concept. The American people have made it mainstream. It has become an imperative. We now need to elect legislators who understand that.

National Health Insurance: Could It Work in the US?

COMMENTARY
The American Journal of Medicine

The US health care system, which depends on private, for-profit health insurance, is not working. It is time for national health insurance!1,2

One would expect that the US, with its well educated population; high standard of living; well trained physicians, nurses, and other health professionals; and well equipped hospitals and diagnostic facilities would provide optimalcare to all its citizens.

A further reason why Americans should expect optimal health care is that the US spends much more for health care than any other country. We pay about twice as much as other countries. In 2005, the per capita health care expense was $6401 for Americans, compared to an average of $3114 in 30 industrial nations in the Organization for Economic Co-operation and Development.3 And, our health care costs keep escalating faster than the rate of inflation.4

We pay more; but we get less for our money! We do not have the world’s best health care. The World Health Organization ranked the US health care system the 37th best of 191 countries, and last among 17 industrialized countries in 2000.5 Our health outcomes: life expectancy, infant mortality, and immunization rates are well behind other industrialized nations.3 In a 2000 survey, 60% of our citizens said that they were dissatisfied with their health care.5

The major reason that our health outcomes are poor is that more than 46 million Americans have limited access to care because they don’t have health insurance.6 Millions of others have inadequate access because they have inadequate insurance. A New York Times/CBS poll in 2007 found that 28% of Americans were without health insurance at some time in 2007, and 61% who were uninsured did not obtain needed care.7

Even though we spend more on health care than any other country, we are the only industrialized country that does not ensure access to health care to all its citizens. The primary source of health insurance in the US is employment-based private (for-profit) insurance which covers 61% of the non-elderly population.6 However, the number covered by employment-based insurance is decreasing8 because some employers, especially small employers, can not afford to provide insurance. The cost of health insurance continues to exceed the rate of inflation. From 2002 until 2007 the cost increased by 78% while the inflation rate increased by 17%.9 As the cost increases some employers stop providing health insurance, or provide insurance with fewer benefits and higher co-pays. Others shift a larger percent of the premium to their employees forcing some employees to drop their health insurance.

More than half of the uninsured are employed, or the dependents of employed persons.6 They lack insurance because their employer doesn’t provide it, and they can’t afford private health insurance. Private health insurance for a family can cost more than $12,000 per year.8 For many older Americans, and for those with “prior conditions” (ie, any known health problem!), the cost of insurance, if it is available, can be out of reach.

Given the high cost of health care, very, very few Americans can afford to pay for health care out of pocket. As a result, Americans without health insurance receive less primary and preventive care and have poorer health outcomes. The bottom line is that the mortality rate for the uninsured is higher than for the insured.10

Our fragmented system of health care, with thousands of health insurance providers, has enormous administrative costs, and for some providers, enormous profits. Only about two-thirds of private health insurance premiums are spent on health care; the rest goes to administrative costs, costs of billing, and profits for the insurance company.11 The overhead in our health care system is more than twice that of countries with a single payer. Administrative costs account for 31% of all health care expenditures in the US, but only 17% in Canada’s single payer health care system.12

In addition, we pay more than twice what other countries do for prescription drugs,13 because, unlike most of the rest of the world, we have no controls on the price of prescription drugs. The Medicare Modernization Act legislation forbids Medicare from negotiating prices with drug companies.14 Many Americans with chronic conditions can’t afford the prescription drugs that can prevent strokes and heart attacks and other conditions leading to death or hospitalization. Multiple studies have shown that many Americans fail to fill or renew prescriptions, or take fewer doses than prescribed because of the costs.15,16

The combination of the excess administrative costs, excess profits, and the excess cost of prescription drugs in the US health care system greatly exceeds what it would cost to provide health care to all uninsured Americans.17 We can decrease health care costs and provide health care to all Americans by adopting mandatory national, non-profit health insurance. The insurance could be financed by a payroll tax shared by the employee and the employer. Premiums would be community-based; that is, they would not be dependent on age or medical history. Patients would have free choice of physicians who would be paid fee-for-service, and have free choice of hospitals and other health care providers.

National health insurance covers the entire population of many European countries at a much lower cost than US health care.18-20 Could such a system of national health insurance work in the US? We already have such a system–it is called Medicare, and it has worked very well for more than 40 years! Medicare pays the private sector to deliver quality health care to more than 44 million Americans. Those who stick with traditional Medicare have free choice of physicians and hospitals. Nearly every US physician and nearly every hospital in the US has elected to participate in Medicare. The administrative costs of Medicare are only 2%21 compared with 12% with for-profit health insurers.12

In a 2003 Pew poll, 67% favored government guaranteed national health insurance even if meant higher taxes,22 and a 2007 New York Times/CBS poll reported that 64% stated that the Federal government should guarantee health insurance for all Americans.7 Maybe the American people are ahead of their legislators!

Why not Medicare for all Americans? It works!

James E. Dalen, MD, MPH
Professor Emeritus of Medicine and Public Health
University of Arizona

Joseph S. Alpert, MD
Professor of Medicine
University of Arizona College of Medicine
Editor-in-Chief, The American Journal of Medicine

References

1. Dalen JE. Health care in America; the good, the bad, and the ugly. Arch Intern Med. 2000;60:2573-2576.
2. Alpert JS. Medical refugees in America. Arch Intern Med. 2000;160: 417-418.
3. Organisation for Economic Co-operation and Development. OECD Health Data, 2007.
4. Catlin A, Cowan C, Heffler S, et al. National health spending in 2005: the slowdown continues. Health Aff. 2007;26:142-153.
5. Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on health system performance. Health Aff. 2001;20: 10-20.
6. Henry J. Kaiser Foundation. Health insurance coverage in America. 2006 data update. October, 2007. Available at: http://www.kff.org/uninsured/upload/7451-03.pdf. Accessed June 10, 2008.
7. Toner R, Elder J, Thee M, et al. Most support U.S. guarantee of health care. The New York Times March 2, 2007.
8. Henry J. Kaiser Family Foundation. Survey of Employer Health Benefits 2007. September 11, 2006. Available at: http://www.kff.org/insurance/7672upload7693pdf. Accessed February 11, 2008.
9. Kaiser Family Foundation. Trends in Health Care Costs and Spending. September 2007. Available at: http://www.kff.org/insurance/upload/7692pdf. Accessed February 11, 2008.
10. Muennig P, Franks P, Gold M. The cost effectiveness of health insurance. Am J Prev Med. 2005;28:59-64.
11. Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff. 2005;24:1629-1639.
12. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003; 349:768-775.
13. Anderson GF, Shea DG, Hussey PS, et al. Doughnut holes and price controls. Health Aff. 2004;W4:396-404.
14. Dalen JE, Hartz DJ. Medicare prescription drug coverage: a very long wait for a very modest benefit. Arch Intern Med. 2005;18:325-329.
15. Rector TS, Venus PJ. Do drug benefits help Medicare beneficiaries afford prescribed drugs? Health Aff. 2004;23:213-222.
16. Tseng CW, Brook RH, Keeler E, et al. Cost-lowering strategies used by Medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage. JAMA. 2004;292:952-960.
17. Himmelstein DU, Woolhandler S. National health insurance or incremental reform: aim high, or at our feet? Am J Public Health. 2003; 93:102-105.
18. Rodwin VG. The health care system under French national health insurance: lessons for health reform in the United States. Am J Public Health. 2003;93:31-37.
19. Reinhardt UE. “Mangled competition” and “managed whatever.” Health Aff. 1999;18:92-94.
20. Christiansen T. A SWOT analysis of the organization and financing of the Danish health care system. Health Policy. 2002;59:99-106.
21. Wilensky GR, Newhouse JP. Medicare: what’s right? what’s wrong? what’s next? Health Aff. 1999;18:92-107.
22. The Pew Research Center. Bush approval slips-fix economy, say voters. August, 2003.

Uwe Reinhardt on the Dutch system

Americans down on the U.S. health-care system

By Kristen Gerencher
MarketWatch
July 13, 2008
Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University.
“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”
Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.
The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.
“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”
http://www.marketwatch.com/news/story/vital-signs-americans-rate-us/story.aspx?guid=%7B86F29D04-FC2D-466F-ADF6-2435468CE406%7D&dist=hpts

The United States currently has a private insurance system that has proven to be quite inadequate in ensuring that all of us receive the health care that we need. Some single out the new Dutch system as a model demonstrating that private plans could work for us if we merely improve the insurance markets and provide a competing public insurance option.
As Professor Reinhardt states, the Dutch system is not even vaguely close to the U.S. system, but rather is a social insurance system in disguise. Merely expanding our private plans to cover more people would not in any way emulate the Dutch system.
Some claim that a single payer system is not politically feasible because it would be too disruptive to our existing health care financing system. Yet they concede that the private insurance industry would have to undergo a massive transformation to eliminate the profound inefficiencies, inadequacies and inequities in our current system. Tight regulation of a totally transformed private insurance industry would certainly be disruptive to these players in our current financing system.
Is disruption really all that bad? The technology industry advances and thrives on innovative disruptions. New, improved, lower-cost technology replaces older, less effective, and more expensive technology. New technology is certainly disruptive to the establishment, but we shed few tears for those older companies that are no longer relevant and are replaced by newer firms.
Our current private insurance industry is functioning so poorly that, at a minimum, it requires wholesale disruption by being transformed into a highly-regulated program of social insurance. But then why should we try to revive an obsolete, last-century system of health care financing when a modern, single payer national health program would be so much more efficient?
Isn’t single payer precisely the disruptive innovation that we now need? And really, who would shed tears over the demise of the private insurers as we know them?

Uwe Reinhardt on the Dutch system

Americans down on the U.S. health-care system

By Kristen Gerencher
MarketWatch
July 13, 2008

Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University.

“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”

Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.

The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.

“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”

http://www.marketwatch.com/news/story/vital-signs-americans-rate-us/story.aspx?guid=%7B86F29D04-FC2D-466F-ADF6-2435468CE406%7D&dist=hpts

Comment:

By Don McCanne, MD

The United States currently has a private insurance system that has proven to be quite inadequate in ensuring that all of us receive the health care that we need. Some single out the new Dutch system as a model demonstrating that private plans could work for us if we merely improve the insurance markets and provide a competing public insurance option.

As Professor Reinhardt states, the Dutch system is not even vaguely close to the U.S. system, but rather is a social insurance system in disguise. Merely expanding our private plans to cover more people would not in any way emulate the Dutch system.

Some claim that a single payer system is not politically feasible because it would be too disruptive to our existing health care financing system. Yet they concede that the private insurance industry would have to undergo a massive transformation to eliminate the profound inefficiencies, inadequacies and inequities in our current system. Tight regulation of a totally transformed private insurance industry would certainly be disruptive to these players in our current financing system.

Is disruption really all that bad? The technology industry advances and thrives on innovative disruptions. New, improved, lower-cost technology replaces older, less effective, and more expensive technology. New technology is certainly disruptive to the establishment, but we shed few tears for those older companies that are no longer relevant and are replaced by newer firms.

Our current private insurance industry is functioning so poorly that, at a minimum, it requires wholesale disruption by being transformed into a highly-regulated program of social insurance. But then why should we try to revive an obsolete, last-century system of health care financing when a modern, single payer national health program would be so much more efficient?

Isn’t single payer precisely the disruptive innovation that we now need? And really, who would shed tears over the demise of the private insurers as we know them?

A system 'in the process of collapse'

By Jeoffry B. Gordon
The San Diego Union-Tribune
July 13, 2008

As a family doctor who has practiced in San Diego for more than 25 years, my daily, intimate experience of providing medical care leads me to strongly dissent from Grace-Marie Turner’s views in “How good is our health care system?” (Opinion, June 30).

Daily I see patients without health insurance who have avoided care, omitted pharmaceuticals they could not afford, or had to use emergency rooms at times of true need and incurred extraordinarily huge charges. Every two or three months I see a patient literally at death’s door due to illness previously unexamined due to financial fears.

Turner does not discuss the fact that bills due to the costs of illnesses are the largest cause of personal bankruptcies in the United States. She omits any discussion of the 47 million uninsured citizens (5 million citizens and 2 million noncitizens in California) cast aside by our “good” health care system to fend as they may.

As a case in point, it is important to note that the American Cancer Society has devoted its annual campaign this year to promoting universal access to medical care. It has determined that being poor or uninsured markedly impairs outcomes of cancer patients, and that making improvements in organizing and financing medical services would save more lives than promoting any scientific or technical innovations in the practice of oncology.

Turner omits any reference to the fact that administrative overhead and profits consume between 20 and 30 percent of health care insurance premium dollars, diverting much of these resources from the provision of health services to enrollees. The total value of money not spent on health services by health insurance companies in the United States approaches $400 billion a year — an amount that approximates the total budget of the Pentagon in 2007 (omitting supplemental appropriations for the Iraq war).

Furthermore, in my own practice I must devote about 5 percent of my time and 25 per cent of my staff time to dealing with the extraordinary complexities of multiple insurance companies and their rules. These are additional resources diverted away from patient care.

Evidently, Turner advocates for a “free-market” approach to medical care. Turning the provision of medical care from a profession into a commercial business has also had a huge impact in distorting the system of health care resources.

There is a huge deficit in (less well paid) general internists, geriatricians and family doctors; there is a surplus of fancy (and expensive) MRIs and PET scanners, etc; public health and sanitation are underfunded (see the current epidemic of tomato-born diarrhea); all resources are scarce in rural areas, and so on. These considerations demonstrate economic as well as production inefficiencies that no “business” would or could tolerate except under cartel conditions when consumers are weak and extraordinary profits can be made.

Frankly, I think the private personal health insurance system is in the process of collapse. Limitations of benefits and cost-sharing (premiums, coinsurance and deductibles) to limit care and improve profit are becoming so onerous that both businesses and individual families are going without, and an extraordinary bureaucracy is smothering health care providers.

The universal tax-financed health insurances we have for people over 65 (Medicare) and veterans and military (Tricare) are both more economically efficient and user-and provider-friendly. In my opinion, a Medicare-for-All program or single-payer health system (such as envisioned in California Senate Bill 840) would provide a tremendous advance in economic efficiency, ease in the provision of care, and represent a real solution to our rich country’s health system deficiencies.

Gordon has practiced family and preventive medicine in Pacific Beach and Ocean Beach since 1983. He completed a residency in family medicine at UCSD Medical Center and served eight years on the California Medical Board, which licenses and disciplines physicians and some allied health professionals.

http://www.signonsandiego.com/uniontrib/20080713/news_mz1e13gordon.html

Health care as a right is hard sell, except outside U.S.

By Wendi C. Thomas
Memphis Commercial Appeal
Sunday, July 13, 2008

What is it like to be sick outside of the United States?

Well, if you are among the 47 million uninsured or 25 million underinsured in America, health care in capitalist democracies such as Switzerland, Germany, Japan, Great Britain or Taiwan is decidedly better than the broken system we have here.

Switzerland requires all its citizens to have coverage.

In Germany, co-payments are only $15 every three months. In Japan, health insurance is private and patients can see a specialist whenever they like.

In Great Britain, doctors get bonuses for improving their patients’ health. Taiwan stores its citizens’ medical histories on electronic cards, which slashes administrative costs.

And in none of these countries do people go bankrupt because of unpaid medical bills.

How do I know this? Because I was at the state’s first house party for the Frontline documentary “Sick Around The World,” a screening organized by the Tennessee Health Care Campaign and the Tennessee Chapter of Physicians for a National Health Program. Retired doctor Art Sutherland is the president of the latter group, and Wednesday night he brought about 30 people into his East Memphis home.

These were people who, for the most part, have health insurance. For them, a lack of health care does not — at least not today — force them to choose between medicine or food.

But they realize that for too many Tennesseans, including the estimated 14 percent who are uninsured, the lack of health care is a matter of life and death.

There is no perfect system — not in any of the countries featured in the documentary, nor in any country in the world. In fact, the documentary made clear that most of the foreign systems don’t bring in enough money to cover the costs.

Unlike Michael Moore’s “Sicko,” this documentary isn’t a politically charged indictment against America as much as it is a call to glean universal health care lessons from our global neighbors.

After all, if Taiwan can insure all its citizens, why can’t we?

Why don’t we?

“It’s a really hard sell that health care is a right,” said Charlotte Borst, a Rhodes College history professor on sabbatical this year. “To me, that’s the biggest issue.”

Once we agree that health care is a right, everything else, Borst believes, is just a matter of figuring out the details of a universal health care system.

One of those who viewed the hourlong documentary was Sandy Arnold, a pediatrician at Le Bonheur Children’s Medical Center and formerly a doctor in Canada.

“It’s part of the Canadian national identity,” Arnold said, that health care for all is a right, and one of the values that distinguishes them from their neighbor to the south.

And therein lies America’s rub. We believe the government is responsible for providing every child an education, and everyone police protection, even that an ambulance should attend to your emergent medical needs.

But the right to health care? In America? It’s not yet part of our national identity.

Shifting that tide — and winning the inevitable fight with the health care and pharmaceutical industries — could take years.

But in the meantime, Sutherland and Emily Snyder, West Tennessee coordinator for the Tennessee Health Care Campaign, hope that voters educate themselves on Sens. John McCain’s and Barack Obama’s health care proposals before heading to the polls. (Get a side-by-side comparison of the presidential candidates’ ideas at health08.org.)

“The United States needs to use its American ingenuity and use the sense of fairness I think we still have to solve this,” Sutherland said.

To get involved

The local organizing group of the Tennessee Health Care Campaign meets next at 5 p.m. Tuesday at the Memphis Center for Independent Living, 1633 Madison. The group meets on the third Thursday of each month, same time and place.

For more information about the organization or hosting your own house party to screen “Sick Around The World,” contact Emily Snyder, the West Tennessee coordinator for the Tennessee Health Care Campaign (thcc2.org), at esnyder@thcc2.org or 590-4873.

Americans down on the U.S. health-care system

Dutch rate theirs most favorably of 10 industrialized nations

By Kristen Gerencher
MarketWatch
July 13, 2008

SAN FRANCISCO (MarketWatch) — International comparisons of health-care systems can be tricky to tease out, but the Dutch appear most satisfied with their system and Americans the least satisfied, according to a new survey of 10 industrialized countries.

The Dutch system was most popular with its citizens while adults in the U.S. were itching for national reform the most, according to Harris Interactive, which cited three separate data sets.

A third of Americans said they believe the U.S. system “has so much wrong with it that we need to completely rebuild it,” while only 9% in the Netherlands hold such a sentiment about their health-care system. Twelve percent of Spaniards favored a complete overhaul, compared with 15% in France, 17% in New Zealand, 18% in Australia and 20% in Italy.

People in the Netherlands also were most likely to say their health-care system works well and needs only minor changes, with 42% holding that view vs. 29% who said so in France. About a quarter of participants in Canada, New Zealand and Australia were fairly satisfied with their health care. The U.S. and Italy were least likely to want minimal changes, with only 12% and 11% supporting just minor tweaks, respectively.

Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University. Had the survey asked participants about their most recent hospital stay, for example, the U.S. likely would’ve scored higher, he said.

“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”
Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.

Americans’ feelings about the U.S. health-care system have remained stable over the last decade, with roughly twice as many saying they want a complete overhaul compared with other nations, said Karen Davis, president of the Commonwealth Fund, a private foundation in New York that has tracked the issue.

What’s more, Americans’ personal share of medical expenses is the highest in the industrialized world, Davis said. In 2007, 30% of Americans reported having out-of-pocket medical expenses of more than $1,000 in the last year compared with 19% of Australians, 12% of Canadians, 10% of Germans and New Zealanders, 5% of Dutch and 4% of Britons.

Accounting for success

The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.

Those polled as the change went into effect may have been reluctant to add any more reforms — even though the system functions pretty much the same way as before, he said.

“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”

Dutch health care also addresses patients’ need for medical attention during nonbusiness hours, Davis said. “The Netherlands has this amazing off-hours system of care so you can always get a nurse or doctor at night or in the evening.”

It’s not just Dutch patients who seem satisfied. In 2006, only 3% of physicians in the Netherlands said they thought their system needed a complete overhaul compared with 9% of U.K. doctors and 16% of doctors in the U.S, according to the Commonwealth Fund.

In some countries that have universal coverage, a sense of pride pervaded the participants’ answers, along with a smaller dose of concern about the systems’ sustainability. In Great Britain, nearly 70% agreed that the National Health Service must be maintained because it’s “crucial” to British society, according to the Harris Interactive survey. But 24% called it a “great enterprise” that probably can’t be maintained in its current form.

Contemplating trade-offs

Majorities in France (70%) and Britain (59%) said their health systems are the envy of the world. Still, nearly as many in France as in the U.S. said fundamental changes are needed to make the system work better. Half of American adults said so compared with 47% of French adults.

Victor Rodwin, professor of health policy and management at New York University’s Wagner School of Public Service, said the French and Danish have among the highest satisfaction rates in European polls of health-system perceptions.

“The French tend to defend their system because they look across the channel and see the British system of rationing and they say that’s not for them,” he said. “They look across the Atlantic and see the U.S. number of uninsured and high prices and say that’s not for them.”

At the same time, some French physicians complain that they’re underpaid and that the system is weighed down by wasteful spending and a lack of responsiveness to consumer preferences, Rodwin said.

In France, people automatically receive a standard, generous insurance benefit that includes prescription drug coverage, he said. They have no deductibles but small copayments. The system is financed largely through taxes.
“What makes France unique is there’s such good access not only to primary care, which you also get in Britain, but also to specialty care,” Rodwin said. “And there’s a high premium on patient choice.”

To be sure, France has one of the most expensive health-care systems in Europe, with expenditures totaling about 11% of its gross domestic product. The U.S. spends 16% of its GDP on health care. Cost containment has been an issue in France for the last 20 years, but unlike the U.S., lawmakers there aren’t talking about national health reform, Godwin said.

Still, cost concerns are growing, he said. “There is an increasing realization that this cannot last forever. There’s constantly new technology and pressure to cover all this and deliver it to the entire population.”

Harris Interactive tapped three sources for its findings. The data for France, Italy, Spain and Germany come from an FT/Harris Poll conducted in June 2008 for the Financial Times. The data for the U.S. and Great Britain come from a Harris Interactive survey conducted for the International Herald Tribune and France 24 in May 2008. The data for the Netherlands, Canada, New Zealand and Australia come from a Harris Interactive survey conducted for the Commonwealth Fund between March and May 2007.

Kristen Gerencher is a reporter for MarketWatch in San Francisco.