PNHP

Physicians’ Rx for an ailing healthcare system: an interview with Claudia Fegan.

Physicians’ Rx for an ailing healthcare system: an interview with Claudia Fegan.

Multinational Monitor
Friday, October 1 2004

Claudia Fegan is president of Physicians for a National Health Program (PNHP), which advocates a universal, comprehensive Single-Payer National Health Program. PNHP has more than 10,000 members and chapters across the United States. Fegan is the medical director of outpatient care at Provident Hospital on the South Side of Chicago. She is a co-author of Universal Healthcare: What the United States Can Learn from Canada (New Press, 2001).

MM: How many people in the United States are without health insurance?

Claudia Fegan: Forty-five million people are uninsured. The majority of those people are either working people or members of their family.

MM: Why aren’t they eligible for Medicaid?

Fegan: The Medicaid requirements vary from state to state. But quite commonly people who are employed, even with minimum wage jobs, earn too much money to receive Medicaid benefits.

MM: So even a minimum wage job puts you above the income threshold for Medicaid?

Fegan: Yes, usually.

MM: Generally speaking, what happens to people who are uninsured who become sick?

Fegan: That also varies from place to place in the country, even from county to county.

For example, I work for the Cook County [Chicago] Bureau of Health Services. We provide care for people who don’t have insurance. We provide care for a lot of people; we’ve provided for over a million outpatients visits last year, the majority for people who were uninsured.

So we provide care for people who don’t have insurance. But uninsured people who are in surrounding counties may not find any kind of network willing to provide care. They may have to make use of a patchwork system, where, for example, private entities agree to accept a certain number of uninsured patients.

One of the classic examples is Washington D.C., our nation’s capital, where the only public hospital closed over a year ago. There, it’s a patchwork system where private practitioners and hospitals agree to take on so many of the uninsured. That is a difficult system for many patients to navigate. Most of those providers require patients to pay some portion of the costs of care. We know from an experiment conducted by the Rand Corporation in the 1970s that a co-payment of as little as one or two dollars will deter patients from necessary care as often as it will deter them from unnecessary care.

MM: If an uninsured person or a partially insured person goes to a facility which doesn’t have any special programs for the uninsured, what’s their experience? Are they going to end up getting care, or will they be turned away?

Fegan: COBRA, which is a federal law, mandates that a person who presents themselves to any healthcare facility–it used to just be the emergency room, but it was extended more than a year ago to include outpatient care facilities–and says they need medical care must receive a medical screening exam. In other words, the healthcare facility must do some type of cursory exam to determine whether or not the person does indeed need care. And that exam should occur before it is determined how that care will be paid for.

Although it is true that you will receive an assessment about whether or not care is needed, that doesn’t solve the problem of how you will pay. Depending upon where you are in the country, you may be able to get care that you need, but you may receive a large bill for it–and the fear of that bill keeps a lot of people out of care.

What does that do for a person who, for example, has hypertension and needs to have their blood pressure checked on a regular basis and needs to receive medication for it? Or for someone who has diabetes? They may not have an emergency, but in order to maintain control of that condition they need to be seen on a regular basis. We know that it is more cost effective to control those conditions and prevent the complications than to wait until the person is sick enough to come to the emergency room. But uninsured people frequently won’t go to the doctor because they are afraid that they will be saddled with debt.

It becomes much more difficult for families with children. The federal SCHIP program [State Children’s Health Insurance Program] was supposed to provide insurance for children, with parents paying for that insurance to the extent that they can. But the program is very difficult to administer. Lots of people who are eligible don’t get enrolled. Or kids whose parents are getting divorced, or who have moved to another state, fall out of enrollment. We know that there was one month in 2002 where the state of New York disenrolled more kids than they enrolled. I know that in 2002 there was a month in Illinois where we enrolled 17,000 kids, but we dis-enrolled 14,000 kids. Someone may have coverage, but by the time they get an appointment, they are no longer eligible for that coverage.

Many people have insurance that is offered to them by their employer, but they can’t afford the amount of the premium. It used to be standard practice that employers would provide insurance for employees as a benefit, and they would charge employees less than 20 percent of the premium cost. But increasingly they charge employees larger percentages of the premium. And the premium may be the same whether you sweep the floors or are a high-level manager. So the amount of your paycheck that would go to the premium may be untenable for those lower wage workers.

MM: Why do services and pharmaceuticals cost more for the uninsured than for people who do have insurance?

Fegan: The insurance companies are able to negotiate discount prices for their enrollees, so the uninsured are the only people who are being charged the full price. Hospitals generally don’t expect to receive the full price from anybody, but if they don’t charge someone that full price, then Medicare says the price is not what the hospital says it is.

So you may price a service at $100 because what you really need is $80, and you know Medicare will pay you $80. Then someone comes in and says I have no coverage, and you say the price is $100.

MM: But for the uninsured it actually is $100, right?

Fegan: For the uninsured it actually is $100. It sure is.

MM: How does the insurance industry affect the kinds of care that people who do have coverage receive?

Fegan: If you’re talking about investor-owned versus other entities, their first responsibility is to their shareholders. The goal of the investor-owned insurance industry is to spend as little money providing care as possible, and they look for all kinds of ways to do that.

Currently, what we’re seeing is a lot more cost sharing because it makes people more skittish about receiving certain kinds of care.

Another common practice is that a lot of insurance companies will not contract with the huge academic tertiary hospitals because they cost more to provide care–they do things that are not available at the small hospitals. So you see patients being shifted to have their cardiac surgery to a smaller hospital, which may do a smaller number of those procedures, and therefore have a higher rate of complications. A lot of these small hospitals are doing cardiac surgery because the reimbursement is good; and what you see is the insurance companies driving business to those smaller entities which offer a lower price. This begins to impact the quality of care that people will receive.

MM: How does Physicians for a National Health Program propose solving these problems?

Fegan: We could take the amount of money that we’re spending on healthcare today, and provide coverage for everyone–including the 45 million people who are uninsured and an additional 50 million who are under-insured, people whose insurance status is tenuous at best. We could do that if we eliminated the 25 to 30 percent of every healthcare dollar that goes to overhead for the insurance industry. Publicly administered plans take less than 5 percent in administrative overhead, so by switching to a public insurance system, we could save enough money to provide care for everyone.

This would be a single-payer form of universal healthcare. When we say universal, we mean everyone. Nobody is left out. We are talking about the government collecting the money that people now pay in insurance premiums, and paying providers. We’re not talking about the government delivering healthcare, we’re talking about the private entities that currently deliver care, continuing to deliver that care–but the government paying for that care.

MM: So would this be roughly modeled on the Canadian system?

Fegan: It would be modeled on the Canadian system. The difference is we’re already spending almost twice as much as Canadians per person on healthcare, so we would have more resources available than the Canadians do. We have enough money to provide high quality, cost-effective care for everyone without the limitations that the Canadians have experienced because their system is being financially strangled.

People would have freedom to choose their provider and what hospital they go to. Patients and physicians could be more concerned about the clinical decision-making as opposed to now, when the kind of coverage you have determines who you can be seen by and what kind of procedure you can have.

MM: What exactly would people pay under such a system?

Fegan: The average consumer today would be paying less than they are currently paying for healthcare.

There would be a line item on their federal income taxes, so that people would pay to the government roughly what they are now, on average, paying to private insurers.

The system would be administered by local health planning boards. Different communities have different needs, and they would place the emphasis in their healthcare dollars in different places. Whereas in Miami it might be more focused on adult and senior care, in New York you might be more concerned about prenatal care for HIV-positive children.

MM: Would employers have to pay?

Fegan: They would still have to pay, roughly the amount that they pay now. Employers that don’t pay anything right now would have to pay. But businesses wouldn’t see a continuous ratcheting up of healthcare costs.

MM: How would the healthcare planning boards work?

Fegan: The healthcare planning boards would receive the dollars from the federal government, and they would receive it on a population basis.

It’s very different, if you’re planning for the healthcare of a community as opposed to what happens now, where a health maintenance organization may be planning for 30,000 people, but who do not all live in the same area. It frees you to address the needs of the area more specifically.

So a healthcare planning board is like a local school board. It is the community looking at its own individual needs. If we have a big problem in terms of obesity, maybe some of our dollars need to be targeted toward weight loss and exercise programs.

This is part of the system in Canada. It works fairly effectively for rural areas, enabling them to address their needs, which may be very different than urban areas. Dollars are allocated based on the needs of the area, and they get very creative. Maybe you don’t have a kidney specialist in your area, how are you going to provide that service to your area? Are you going to provide financial enticements for someone to come settle there? Or maybe there is someone in the next town who may be able to provide you with coverage. Or maybe some of your care can be provided via computer, with the patient only needing to travel periodically to be seen by the specialist in that town.

Various communities solve their problems differently, but at least they have the dollars to look at their needs and then decide how they want to allocate them.

MM: How would providers–doctors, hospitals–be reimbursed for the care they provide?

Fegan: Doctors’ fees would be negotiated by the various medical societies. The American College of Cardiology would say this is what is a reasonable fee for a cardiologist doing an office visit, this should be the fee for a cardiac catheterization. Then the health planning board would reimburse them for the care they have provided.

Hospitals would no longer have to keep track of every aspirin they dispense. The health planning board would say, this is the population; based on how many people you saw last year, this is how many people you will probably see in the coming year; based on how much it cost you to do it last year, and taking into account inflation, we will pay you “X” to provide the same service. No longer will hospitals have to pay a lot of staff to do a lot of bookkeeping. They won’t have to count how many times they had to stick this person to start an IV and charge him for each needle they have used.

MM: Is there a danger in such a system of creating an incentive for doctors to see too many patients and then give each of them too little care?

Fegan: Medical societies can set limits. In other words, if they say an orthopedic surgeon working reasonably for a given population should only replace “X” number of knees in a course of year, when the surgeon gets to that number and begins to do more than that, then they are going to get paid less for each procedure they do. That ceiling would be determined by the various specialty societies, by the doctors’ peers.

MM: Will there be rationing in such a system?

Fegan: We’re rationing care now. Right now we’re rationing care based on ability to pay for it. If you have enough money, you can get it.

We would allocate care based on need; so the people that need it the most get it first.

The dollars for healthcare are not infinite, and so we have to decide what is the most reasonable way to provide care.

Some people like the current system. They like the idea that if you are wealthy, you can purchase the care you need; and if you can’t, well, best of luck to you.

But some people believe that it is not unreasonable to decide that people that need care the most, deserve it. When a small child is sick, the question becomes, what child doesn’t deserve to receive the best care available? And how do we decide, because you had the misfortune to be born to blue-collar parents, that you can’t have the same care as someone who was born to parents who could afford to give you whatever care you needed?

MM: How is this kind of system received in Canada?

Fegan: It’s immensely popular. If Medicare is the third rail of U.S. politics, this is the Canadian third rail. It is the thing which Canadian politicians have learned not to toy with. It remains one of the most popular programs in Canada; and the public wants it expanded, not decreased, and they are willing to pay more taxes to expand it.

MM: How does business view the system in Canada, and how do you think large corporations would view the same proposal in the United States?

Fegan: We know that the cost of healthcare hurts American companies’ ability to compete internationally. It raises their cost of doing business in this country. So companies really like the idea of not having to fight over healthcare.

If you look at the strikes that have occurred in this country over the last few years, healthcare has always been one of the major issues, if not the major cause of the strike.

Unions are increasingly beginning to believe that this is not an issue they can win on in bargaining agreements with individual employers. In the long grocery workers strike in California last year, for example, the United Food and Commercial Workers finally were able to hold on to benefits for the veteran workers, but new hires do not get the same level of healthcare benefits.

MM: Given all these arguments about why the United States should have such a system, what’s the program to overcome the political roadblocks?

Fegan: Right now there is a lot of money with heels dug in to stay with the current system.

But this is one of those issues that stirs emotions in people and will eventually push aside the interests blocking change. When people become vehement about this, political will somehow occurs. And as more and more people are suffering in the current system, emotions are moving in this direction.

We don’t expect Washington politicians to lead the way. This is something that the public will demand, and then the politicians will get behind it.

The problem we have right now is that the lobbyist system is so dysfunctional and so grotesque it takes more people to overcome the interests opposed to change.

But we are slowly moving in the right direction. More and more physicians are signing on to the call for a national health plan, and more and more of the general public is becoming educated. They figure there has got to be something better than what we’re doing, because what we’re doing surely isn’t working for them.

The example of South Los Angeles

A City Where Hospitals Are as Ill as the Patients

By Jennifer Steinhauer
The New York Times
June 5, 2008

For thousands of residents of South Los Angeles who had depended on the large county-run King-Harbor hospital, the past 10 months have been a grueling exercise in cobbling together medical care. When King-Harbor was shut by federal officials, it became the 15th general acute care hospital to close in Los Angeles County since 2000, about half of which served residents in South Los Angeles.

The loss of King-Harbor was less a seminal moment than another episode in the continuing health care ordeal among this city’s sickest and poorest residents.

South Los Angeles is one of the most difficult places in the nation to both receive and give medical care. Family doctors are few and far between, and the area is one of the hardest to draw new doctors to, physician recruiters say.

The vast majority of residents in central Los Angeles are uninsured or are on the state’s Medicaid program — known as Medical — which offers the lowest reimbursement rates in the nation, and a growing population of illegal immigrants who are not eligible for government insurance have flooded the ranks of the uninsured.

Gov. Arnold Schwarzenegger, a Republican, has proposed another 10 percent cut in the state’s Medicaid program to balance the state’s budget while Congress contemplates a host of reductions to the program that, if approved, would mean $240 million less for Los Angeles.

From 2000 to 2006, the number of Medicaid-covered patients using the South Los Angeles hospitals on Medicaid increased 18 percent and the uninsured ranks rose more than 20 percent, while patients with commercial coverage fell 20 percent, according to the hospital association’s figures.

As a result, many hospitals in the South Los Angeles area are unable to stay afloat, and centers that once served 100,000 patients here have closed.

http://www.nytimes.com/2008/06/05/us/05southla.html

Comment:

By Don McCanne, MD

There are a great many problems that must be addressed if we are to ensure that people in underserved regions, such as South Los Angeles, have access to adequate health care services. But there is one absolutely essential resource that must be available to establish the necessary health care infrastructure: money.

When government budgets are perceived to be tight, where do our elected officials turn to try to reduce spending? Amongst the more vulnerable sections of budgets are the various health programs for low-income individuals – a sector of our society with only a feeble political voice. Reform proposals that would build on our current fragmented system of financing health care would continue to perpetuate this chronic underfunding stemming from the acquiescent anti-welfare mentality of those participating in the budget process.

Without adequate funding, health care will not be provided. The first step is to make sure that the money is there. A single payer national health program would do precisely that. All facilities and services would be fully funded. More work certainly would have to be done, but the financial barrier would have been removed.

There is reason for pessimism. A tour of the medical facilities in South Los Angeles is confirmation that, whatever makes America great, it is not our social solidarity. Maybe we need to start a campaign against acquiescence. Then maybe we’ll find the spark needed to ignite our social solidarity.

National Demonstrations Against Insurance Company Denials and Rejections of Patients

Healthcare-NOW!
June 19, 2008

Click here for the flyer for this demonstration.

We need to emancipate ourselves from these corporations!

On June 19th, 2008, the American Health Insurance Plans (the trade group of the thousands of insurance company executives) will have their annual meeting in San Francisco. June 19th is also the national day of celebration of the emancipation from slavery for millions of Americans. Healthcare-NOW will be combining activities on both.

Healthcare-NOW, and hundreds of other organizations, is holding events nationwide, in as many as 18 cities, both celebrating the official end of slavery and challenging the corporate enslavement of our health care system. Healthcare-NOW and thousands of other cities, counties, state governments, and labor unions have endorsed and support H.R. 676, a national guaranteed healthcare system that will cover everybody without co-pays, deductibles, premiums or denials.

Demonstrations will be held in front of the largest and wealthiest multi-billion dollar companies exposing and indicting their practices that have, for so long, kept us from having a national health insurance plan with equality for all in this nation with no financial barriers to care.

San Francisco, CA: The largest demonstration, sponsored by hundreds of organizations including the California Nurses Association and the California Universal Health Care Organizing Project is leading the nation to expose the American Health Insurance Plans at their national conference in San Francisco on June 19th. More than 38,000 insurance company executives are expected to attend.

Heal th Care YES! Health Insurance NO!

Guaranteed, Single-Payer Health Care NOW!

Join San Francisco in solidarity to protest the insurance companies around the country!

San Francisco, Mosconi Center, 1PM, Bill Gallagher: bgallagher@calnurses.org
Baltimore, Care First Blue Cross, 5PM, Rod Ryon: info@mdsinglepayer.org
Philadelphia and Camden, Cigna, Kathleen Casey: kcasey@pennanurses.org
Pittsburgh, Highmark/Blue Cross/Blue Shield, Sandy Fox: sm2fox@yahoo.com
Minnetonka, MN, Stockholder’s Meeting of United Health Care, Joel Albers: joelalbers@UHCAN.org
Oklahoma City, Blue Cross/Blue Shield, Reggie Cervantes: clipedwingangel@yahoo.com
Louisville, KY, Humana, Kay Tillow: nursenpo@aol.com
Jacksonville, FL, Blue Cross/Blue Shield, 5PM, Mark Piotrowski: markp@floridalaborparty.org
Chicago, IL, Cigna, Jill: chisinglepayer@gmail.com
Indianapolis, IN, Wellpoint Shareholder’s Meeting (May), Cindy Calley: home@calleys.org
San Antonio, TX, Humana Insurance Co, 6PM, Jane Lee Cantu: janelee@satx.rr.com
Newark, NJ, Blue Cross/Blue Shield, 12PM, Ray Stever: rayiuc@aol.com
Atlanta, Blue Cross/Blue Shield, 3PM, Margie Rece: msrece@yahoo.com
New York City, GHI and United Health 5PM, Billy Wharton: noprivatization@yahoo.com
St. Louis, MO, Julia Lamborne, Julia0409@aol.com
Albany, NY, Leo O’Brien Federal Building, 5PM, Mike Keenan: mikekeenan@pefencon.info
Boston, MA Association of Health Care Plans, Janet Hand: Jlynnxo@aol.com

Congressional response to Obama as president

We must resuscitate the system in order to expand coverage, lower cost

By Rep. Pete Stark
The Hill
June 3, 2008

Recent surveys indicate that a majority of Americans share a strong hope that the next occupant of the White House will work with the Congress to address this issue. As we have learned from past attempts, the best-laid plans of any one party, interest group, or industry are insufficient to achieve the goal. Success will require negotiation and compromise from everyone. Our private profit, non-profit and public programs must work in harmony to bring about needed change.

http://thehill.com/op-eds/we-must-resuscitate-the-system-in-order-to-expand-coverage-lower-cost-2008-06-03.html

We are still full throttle at Senate Finance Committee

By Sen. Max Baucus
The Hill
June 3, 2008

On healthcare reform, Sen. Chuck Grassley (R-Iowa) and I will convene a bipartisan summit at the Library of Congress on June 16 called “Prepare for Launch: Health Reform Summit 2008.” It will be an opportunity for senators, representatives and health policy experts to dig in to prepare for health care reform in 2009. Federal Reserve Chairman Ben Bernanke and genomic research pioneer Dr. J. Craig Venter will address attendees. We will take up issues like state-based reform efforts, employer-sponsored coverage trends, rising healthcare costs, demographic shifts, insurance market reform, the role of public programs and delivery system reform.

http://thehill.com/op-eds/we-are-still-full-throttle-at-senate-finance-committee-2008-06-03.html

Comment:

By Don McCanne, MD

Those of us who have long been advocating for health care reform are encouraged by the the window of opportunity that has opened with the change in political climate. There is a high probability that in January, Barack Obama will be president, we will have a strong Democratic majority in the House of Representatives, and Democrats may even constitute a filibuster-proof majority in the Senate.

When President Obama calls on Congress to begin the process for reform, what response can we anticipate based on the views of highly credible Democratic veterans of the legislative process?

Rep. Pete Stark calls for resuscitating the system. He calls for opening the process from a position of compromise that includes the for-profit and nonprofit private insurance industry. Sen. Max Bacus doesn’t even go that far. He calls for incremental steps that are so small that they would be overwhelmed by our backwards slide from our goals of reform.

Based on the statements of several politicians, it is likely that the early initial measures will be passing the children’s insurance bill (SCHIP) that Pres. Bush vetoed, and undoing some of the damage done to Medicare by the Medicare Modernization Act.

Soon after, negotiations should then begin to craft legislation for a “universal” system of health care coverage. On one end of the debate would be the Stark/Hacker/Obama model of public programs plus a choice of either private plans or a public Medicare-like option. On the other end would be the Wyden/Bennett/McCain model of competing private plans, with or without an individual mandate to purchase insurance.

Where will the compromise process take us? There is considerable support for a public Medicare-like option that theoretically could serve as a vehicle for eventual transformation into a single payer system. For that same reason, there is very strong opposition from Republicans who perceive it as a program that would take us down the road to socialized medicine. The public option supported by progressives would be very expensive because of its comprehensive benefits and the impact of adverse selection. If such an option were included in the final legislation, Republicans and conservative Democrats would see to it that it would be an underfunded, bare bones program designed to encourage individuals to remain in the private insurance market. It is even more likely that the public option would be discarded in the negotiation process, primarily because of the complexities of another welfare program that wouldn’t serve the public well.

It is recognized that lower-income individuals cannot afford to pay health insurance premiums. Although a cumbersome system of premium subsidies could be devised, it is much more likely that Congress would rely on expansions of our existing underfunded welfare programs: Medicaid and SCHIP. The decline in access due to a lack of willing providers is simply a price you pay for the process of political compromise.

Medicare would likely be left alone after the initial damage control measures were enacted. It is likely that Medicare funding will not keep up with medical costs in an attempt to delay the financial train wreck predicted by many. Lower funding would result in a decline of participating physicians.

What about the rest of us? Easy. Simply reform the private insurance markets. Require that insurers offer coverage to everyone, regardless of preexisting conditions. Require that plans provide coverage generous enough to prevent financial hardship for those who do have health care needs. Prohibit the sale of innovative underinsurance products that would leave sick people financially destitute, while shifting their costs to the rest of us. Require that higher-income free-riders either purchase private coverage or contribute to a public pool. Prohibit the private insurers from wasting money on administrative excesses, keeping their costs at 15 percent of the premiums (while doing nothing about the administrative burden on providers).

Fine. Then have the private insurers get out their sharpened pencils and give us the very lowest premium prices possible for products actually meeting these standards. (Hint: California’s CalPERS, the third largest health benefit purchaser in the nation, offers PERS family plans at premiums ranging from $13,998 to $23,163.)

Talk about train wrecks. The private insurance industry cannot possibly offer plans with affordable premiums that provide reasonably comprehensive benefits for all risk categories.

So what will be the political compromise? Congress would never provide enough taxpayer subsidies to make these plans affordable (likely well over a half trillion dollars). They can’t mandate individuals to buy insurance they can’t pay for. They could provide partial subsidies, but the experience in Massachusetts, the experience with tax credits for trade-displaced workers, and the experience of state high-risk pools demonstrate that comparatively few individuals participate in these plans, even with fairly generous subsidies. Okay, so we can’t cover everyone with private plans, but, again, that is the price of political compromise.

Wait. We could do something else. We could get rid of the private insurance industry and adopt a single payer national health program. Presidential candidate Obama has already indicated that a single payer program would be a much better system of financing health care than our current fragmented system of a multitude of private and public plans.

We can have single payer if the people ask for it, but first they must understand why private plans will never work. John Geyman explains precisely why in his new book, “Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It.” Order your copy now, if you haven’t already. You’ll need it in the coming months as we debate reform.

“Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It:”
http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

Dr. Paul Farmer Challenges Profit-Driven Medical System While Bringing Healthcare to Poor Communities Worldwide

Democracy Now
National Public Radio
May 28, 2008

Click here for the full interview.

Paul Farmer is not your ordinary doctor. In going to the poorest places on earth, he is not only treating patients, but challenging whole healthcare systems. More than twenty year ago, Dr. Farmer co-founded the charity Partners in Health to provide free medical care in central Haiti. Today, Partners In Health provides healthcare for people with HIV/AIDS, tuberculosis, malaria and other conditions in Haiti and eight other countries around the world. We spend the hour with Dr. Farmer on his work, his remarkable background and the challenges of pursuing healthcare with a social justice perspective.

AMY GOODMAN: Before we get to the end of the broadcast, I want to come back here, because your analysis is not just a medical diagnosis, but it is an analysis of the healthcare system, and that’s ultimately what you’re challenging. So we’re in a presidential year. Healthcare is a critical issue, as long as you’re not watching the media, where you hardly see it discussed. But what do you think of the healthcare system in this country? What has to be done? How do you think–what do you think of the candidates and what they’re representing?

DR. PAUL FARMER: Well, my diagnosis of our healthcare system’s problems is that it’s very expensive to give bad medical care to poor people in a rich country, very expensive to give bad medical care to poor people in a rich country. And I can give example after example from my own clinical experience working in, you know, the best hospitals I’ve ever seen in the world. And like I said, when they’re in the hospital, things go OK. But we do not have a good safety net. We don’t have a good primary healthcare system.

And to get into the hospital, the uninsured–47 million people, maybe 50–they have to pass through an emergency room, waste time, and things happen to them there that probably shouldn’t, because they’re primary healthcare problems, they’re in an emergency room. And then again, on top of that 47 million, probably just as many Americans are poorly insured and can be thrown into destitution by serious illness. So, you know, there’s 100 million Americans who are in–are not–they don’t have health security. They don’t know that a devastating illness could not wipe out their savings or make them lose their home. They may know that. I hope they do.

AMY GOODMAN: What does the term single-payer mean to you?

DR. PAUL FARMER: I think it’s a good idea. I mean, again–

AMY GOODMAN: If someone doesn’t understand it, in a sixty-second quoteĆ¢ā‚¬Ā¦

DR. PAUL FARMER: Single-payer means, to me, that there’s a national health insurance program that is not divvied up, you know, state-by-state. You know, I was reading about Oregon yesterday on the plane on the way up here, and they’re talking about a lottery to see who’s going to get health insurance. Of the people who applied, it’s going to be some tiny little fraction. Using a lottery to allocate health insurance doesn’t seem to me like a great idea. In Massachusetts, where much has been made of universal access, what’s really happened is that medical insurance is made mandatory, which is different from a national health insurance program or a social safety net. And, you know, I don’t mean to be ideological about this. I’m not. I’m just saying we live in a country that is putting out 16 to 17 percent of our GDP for healthcare and not getting the returns that we need. And from the analyses that I read, having a national health program would cut out some of these unnecessary expenses. I think that’s a sound analysis.

AMY GOODMAN: And you’re a voting participant in this society. What do you think of what the candidates are offering?

DR. PAUL FARMER: Well, you know, they’re–well, I’m not going to talk about the Republican likely nominee, because I don’t think that’s going to be much of a difference. The Democratic nominees are not really shaking the foundations of this system. Whether they will or would if they could, I don’t know. But again, the right to healthcare is different from mandating. You know, car insurance is mandatory right? So you’re not supposed to drive a car–and if you get pulled over when you don’t have insurance, you could have your car impounded. That’s not a great approach to healthcare and insurance. And I don’t think that’s going to be enough.

And so, I’ll be a goodwill participant. And other people I mentioned–my colleague, Jim Kim, who is a real policy guru–we have people on our team–I included–who will participate in trying to be active members of a society that needs a national health insurance program. I mean, I don’t know–I’m sure that the path forward is going to be very complex. But a lot of times people say, well, it’s much more complex than that. You know, there’s also a simplicity to it; it’s we don’t have a social security net for the ill or those likely to become ill .

Auctioneers of medical debt

Hospitals Put Patients' Debt Up for Auction

By Sarah Rubenstein
The Wall Street Journal
June 3, 2008

In a move that consumer groups say could increase pressure on people with unpaid medical bills, some hospitals are trying out a new tactic to recoup patients’ debts: They’re auctioning the debt online.

Hospitals have long relied on outside collection agencies to go after debtors. Under traditional arrangements, these agencies receive a percentage of any money they get from a debtor; the more they collect, the more they earn.

Now, some of the same collection agencies, as well as other firms that purchase debt outright, have begun participating as bidders in online auctions, in which they buy the debt or provide guaranteed payments to hospitals for access to the unpaid accounts. Some experts say this gives them more reason to aggressively pursue patients in arrears. Auctions can drive up the amount paid for debt, meaning a collector must recoup more money from patients to cover its initial investment and turn a profit. And the winning bidders often get to keep all the money they collect on the auctioned debt.

Many of the auctions of hospital debt have been done through Web site ARxChange.com — shorthand for “accounts receivable exchange” — owned by TriCap Technology Group. Another site is medipent.com, run by Medipent LLC.

“The hospital is an institution in the community, has a reputation, in many cases has a nonprofit mission to uphold,” says Anthony Wright, executive director of the consumer-advocacy coalition Health Access California. “Once it goes to collections, that starts a process that can get a lot more antagonistic, a lot more aggressive, and a lot more damaging to a family’s credit history and financial future.”

http://online.wsj.com/article/SB121244901525139563.html

Comment:

By Don McCanne, MD

By far, the highest per capita health care spending in the world… the money is already there… and, yet, we are unique amongst industrialized nations in forcing into debt individuals who have the misfortune of becoming ill or injured.

Of all of the problems we face, this is one of the simplest. We do not need more money. We merely need to reform our system of financing health care.

So what do we do? We continue to expand policies that make all of the numbers worse – more uninsured, more underinsured, more medical debt, greater impairment of access, greater administrative waste… while we continue to support the multitude of money-movers, trading off the health and financial security of patients.

Today’s message is particularly disturbing. Medical debt is a horrendous problem. Instead of trying to fix the financing system so that medical debt is prevented, we add yet another administrative layer that further burdens those with medical debt: the auctioneers who sell medical debt to the highest bidding collection agencies!

Have we no shame?

Sen. McCain's proposal for high-risk pools

McCain's Free-Market Health Plan Would Boost Role of High-Risk Pools

By Laura Meckler and Anna Wilde Mathews
The Wall Street Journal
June 2, 2008

John McCain’s plan for a health-care system built around consumers shopping for their own insurance comes with a significant downside: for people with a history of illness, it can be impossible to find coverage on their own.

The Republican presidential candidate’s main answer is to bolster the role of high-risk pools, which sell insurance to people with pre-existing conditions such as diabetes, cancer and AIDS.

These pools, typically created by state governments, require significant government subsidies, charge high premiums and sometimes sharply restrict benefits or enrollment. Nationally, fewer than 200,000 people are enrolled in such pools, while 47 million people in the U.S. are without insurance.

“They tend not to work particularly well,” said Sara Collins, an assistant vice president at the Commonwealth Fund, a nonprofit health-care-research group. “States have really struggled to finance these adequately.”

Sen. McCain… would rely on tax cuts, market forces and consumers themselves to broaden access to coverage, and give a smaller role to employers as a source of coverage.

To fill the gap, Sen. McCain proposed new high-risk pools that would scoop up those who can’t get insurance on their own. He called it a Guaranteed Access Plan. Premiums would be reasonable, with subsidies for low-income participants, but he has given few other details.

(Douglas Holtz-Eakin, Sen. McCain’s chief policy adviser) has suggested the federal government might need to spend $7 billion to $10 billion to subsidize these pools — an estimate he calls “extremely preliminary.” Many experts said that is nowhere near enough, particularly given the large number of people with pre-existing conditions who would need this help if employers send their workers out to the open market.

http://online.wsj.com/article/SB121236916701936663.html?mod=googlenews_wsj

Comment:

By Don McCanne, MD

Sen. John McCain’s initial proposal for health care reform was simply to change tax incentives, reducing support for moderately-regulated, employer-sponsored health plans, and providing tax credit incentives that would encourage individuals to shop in the less-regulated, individual insurance market – a market capable of providing a much greater choice of innovative health plans. It quickly became obvious that these innovative products would be designed to avoid paying for much of our health care. He had to come up with a proposal to answer critics of his plan.

Over half of us receive our coverage through employer-sponsored group plans. Although employer-sponsored plans cover a lower-cost, healthier segment of our population, health care has now become so expensive that premiums for these more comprehensive plans have become much less affordable. Employers have been attempting to reduce their costs by trimming benefits and expanding out-of-pocket expenses for their employees, but even these changes have failed to make premiums affordable.

Sen. McCain contends that a less-regulated individual insurance market is capable of offering innovative products with premiums that would be affordable for most of us if we were to use his proposed tax credit. In reality, the tax credit is not large enough to make premiums affordable for plans comparable to what most employers provide. For premiums to be competitive, the plans would have to reduce benefits and require much greater out-of-pocket cost sharing. These plans would work only for individuals who are healthy and who will remain healthy, defeating the purpose of insurance.

In a less-regulated market, more comprehensive coverage comparable to current employer-sponsored plans attracts individuals who have greater health care needs. It is unlikely that those plans would even be offered in the individual market under Sen. McCain’s proposal, but if they were, they would rapidly withdraw from the market because of the death spiral caused by the ever higher premiums that must be charged as the sick enroll and the healthy drop out. People who need care would be shut out of the individual market.

Sen. McCain could not really sit on a proposal that would cover only the 80 percent of us who are healthy. He had to propose some mechanism of paying for the 80 percent of health care that is used by the 20 percent of us who have significant health care needs. His solution is to promote state-run high-risk pools that would provide that coverage.

We do already have considerable experience with these pools, and it certainly is not good. The primary problem is that the cost per participant is extremely high. Most states severely restrict the number of participants, and many states haven’t even established such pools. The high premiums are even less affordable, and coverage is very skimpy, usually with very low lifetime caps.

In 2006, private plans, out-of-pocket expenses, and other private spending financed 54.7 percent of national personal health care expenditures (KFF/Urban Institute). CMS projects for 2008 a total personal health care expenditure of $1,999 billion. Thus private health care spending is projected to be $1,093 billion this year. The 20 percent of health care consumed by the 80 percent of us who are relatively healthy would cost about $218 billion. The 80 percent consumed by the 20 percent of individuals with significant health care needs would cost about $874 billion in private spending.

It is much of this $874 billion that would be transferred to the state high-risk pools under Sen. McCain’s proposal. His adviser, Douglas Holtz-Eakin, provides an “extremely preliminary” estimate of $7 billion to $10 billion in federal subsidies for these pools. Who pays the other $864 billion? The individual?

Excluding those covered by Medicare, Medicaid and other public programs, 225 million of us have private insurance or are uninsured. Twenty percent of those, or 45 million people, theoretically would be in the high-risk pool if everyone were to obtain coverage under his program. If the high-risk individuals were responsible for the remaining $864 billion, each would have to pay $19,200. Obviously, that can’t work.

Others propose that high-risk pools be funded by an assessment on commercial insurers. But that moves the financing for high-risk individuals back into the private insurance risk pools. Not only would that drive up premiums, which are already unaffordable, it would also add another layer of administrative costs in a system that is already overburdened with administrative excesses.

Now you know why state high-risk pools don’t work. There is only one reason to propose them in the first place – that is to relieve the private insurance industry of its responsibility of paying for necessary health care, merely to enhance its successful business model of selling insurance primarily to the people who don’t need care now, and hopefully won’t in the future.

As John Geyman says, the private insurance industry is dying, and we shouldn’t try to resuscitate it – certainly not if we we taxpayers are the ones who are going to be indemnifying those who actually need health care.

Empty promises on health care

By Marie Cocco
Indy Star
May 31, 2008

More than halfway through a political season in which public concern about America’s porous, confusing and costly health insurance system has consistently emerged as one of the chief worries of a squeezed electorate, this is what we can expect when the new president takes office next year: not so much.

Neither presumptive Republican nominee John McCain nor Democrat Barack Obama, the likely nominee of his party, has pledged to cover all of the 47 million uninsured Americans who are falling through the cracks of a system that already is at a breaking point. Neither has proposed a health-insurance plan that would make health care more fair and equitable by putting everyone in a pool in which risks are shared among those who are healthy (but might one day get sick) and those who are not. This is how insurance — whether it be government insurance, such as Social Security, or private insurance, such as the policies we buy for automobiles — works. With everyone in the same system, everyone shares the burden of paying as well as the benefit of coverage when it is needed.
Because of the crucial failure of both candidates to acknowledge this elemental truth, the nation will likely stay on the crooked path down which it has staggered since the employer-based system of care began to unravel at least two decades ago.

But don’t both McCain and Obama say they want to fix the system, covering more people and lowering costs for everyone? Sure. But talk is cheap — much cheaper, apparently, than the political costs of more comprehensive action that would either anger ideological supporters on the right (if you’re McCain) or raise that old chestnut about “socialized medicine” (if you’re Obama).

McCain’s plan, because it seeks to placate a right wing for whom any hint of government intervention is apostasy, would effectively dismantle the current employer-based system by eliminating the tax deduction that businesses now get when they pay the health premiums for their employees. Most experts say this would quicken the pace at which employers are dropping coverage.

McCain would provide tax credits for individuals to purchase insurance, but he relies on the unproved theory that if full costs and responsibility for insurance were shifted back to individuals and families, prices would drop. “This is a ‘back to the future’ plan, returning us all to the period before the creation of employer-based group insurance in the 1930s, when individuals and families were ‘on their own’ to find ways of paying for their health care,” concludes an issue brief by Rekindling Reform, a New York-based group of religious, academic, social welfare agencies, unions and public health organizations.

Obama’s plan is a lost opportunity.

Yes, it would curtail some of the more egregious insurance industry practices and seeks some cost-containment. But it still fails to recognize that without some kind of mandate to bring everyone into the system — either an individual mandate, like his Democratic rivals Hillary Clinton and John Edwards proposed, or a nationwide requirement, such as a Medicare-for-all type of system — insurance companies still would be able to cherry-pick among those they want to insure and those they don’t.

“Where his (Obama’s) falls down is that it’s not universal,” says Aaron E. Carroll, director of the Center for Health Policy and Professionalism Research at Indiana University School of Medicine. “He’s still trying to build this on a patchwork system.”

Though Obama proposes a mandate that all children be covered, he has no clear way to enforce this beyond what many states already do for the current State Children’s Health Insurance Program (SCHIP). That is, he would do outreach at schools, day-care centers and hospitals to try to get parents to sign their kids up. “Mandates like this are incredibly inefficient,” Carroll says, and would be unlikely to enroll many more children than the state and federal governments already have.

The good news, I suppose, is that if McCain wins the White House, Democrats probably will continue to control Capitol Hill. They would be unlikely to enact anything so radical as the McCain proposal. The bad news is that if Obama wins, his party will have squandered the best opportunity in more than a decade — since the Bill Clinton era — to take a bold leap toward the universal coverage Democrats have promised since the presidency of Harry Truman.

Cocco writes for the Washington Post Writers Group. Contact her at mariecocco@washpost.com.

Sen. McCain’s proposal for high-risk pools

McCain’s Free-Market Health Plan Would Boost Role of High-Risk Pools

By Laura Meckler and Anna Wilde Mathews
The Wall Street Journal
June 2, 2008

John McCain’s plan for a health-care system built around consumers shopping for their own insurance comes with a significant downside: for people with a history of illness, it can be impossible to find coverage on their own.

The Republican presidential candidate’s main answer is to bolster the role of high-risk pools, which sell insurance to people with pre-existing conditions such as diabetes, cancer and AIDS.

These pools, typically created by state governments, require significant government subsidies, charge high premiums and sometimes sharply restrict benefits or enrollment. Nationally, fewer than 200,000 people are enrolled in such pools, while 47 million people in the U.S. are without insurance.

“They tend not to work particularly well,” said Sara Collins, an assistant vice president at the Commonwealth Fund, a nonprofit health-care-research group. “States have really struggled to finance these adequately.”

Sen. McCain… would rely on tax cuts, market forces and consumers themselves to broaden access to coverage, and give a smaller role to employers as a source of coverage.

To fill the gap, Sen. McCain proposed new high-risk pools that would scoop up those who can’t get insurance on their own. He called it a Guaranteed Access Plan. Premiums would be reasonable, with subsidies for low-income participants, but he has given few other details.

(Douglas Holtz-Eakin, Sen. McCain’s chief policy adviser) has suggested the federal government might need to spend $7 billion to $10 billion to subsidize these pools — an estimate he calls “extremely preliminary.” Many experts said that is nowhere near enough, particularly given the large number of people with pre-existing conditions who would need this help if employers send their workers out to the open market.

http://online.wsj.com/article/SB121236916701936663.html?mod=googlenews_wsj

Comment:

By Don McCanne, MD

Sen. John McCain’s initial proposal for health care reform was simply to change tax incentives, reducing support for moderately-regulated, employer-sponsored health plans, and providing tax credit incentives that would encourage individuals to shop in the less-regulated, individual insurance market – a market capable of providing a much greater choice of innovative health plans. It quickly became obvious that these innovative products would be designed to avoid paying for much of our health care. He had to come up with a proposal to answer critics of his plan.

Over half of us receive our coverage through employer-sponsored group plans. Although employer-sponsored plans cover a lower-cost, healthier segment of our population, health care has now become so expensive that premiums for these more comprehensive plans have become much less affordable. Employers have been attempting to reduce their costs by trimming benefits and expanding out-of-pocket expenses for their employees, but even these changes have failed to make premiums affordable.

Sen. McCain contends that a less-regulated individual insurance market is capable of offering innovative products with premiums that would be affordable for most of us if we were to use his proposed tax credit. In reality, the tax credit is not large enough to make premiums affordable for plans comparable to what most employers provide. For premiums to be competitive, the plans would have to reduce benefits and require much greater out-of-pocket cost sharing. These plans would work only for individuals who are healthy and who will remain healthy, defeating the purpose of insurance.

In a less-regulated market, more comprehensive coverage comparable to current employer-sponsored plans attracts individuals who have greater health care needs. It is unlikely that those plans would even be offered in the individual market under Sen. McCain’s proposal, but if they were, they would rapidly withdraw from the market because of the death spiral caused by the ever higher premiums that must be charged as the sick enroll and the healthy drop out. People who need care would be shut out of the individual market.

Sen. McCain could not really sit on a proposal that would cover only the 80 percent of us who are healthy. He had to propose some mechanism of paying for the 80 percent of health care that is used by the 20 percent of us who have significant health care needs. His solution is to promote state-run high-risk pools that would provide that coverage.

We do already have considerable experience with these pools, and it certainly is not good. The primary problem is that the cost per participant is extremely high. Most states severely restrict the number of participants, and many states haven’t even established such pools. The high premiums are even less affordable, and coverage is very skimpy, usually with very low lifetime caps.

In 2006, private plans, out-of-pocket expenses, and other private spending financed 54.7 percent of national personal health care expenditures (KFF/Urban Institute). CMS projects for 2008 a total personal health care expenditure of $1,999 billion. Thus private health care spending is projected to be $1,093 billion this year. The 20 percent of health care consumed by the 80 percent of us who are relatively healthy would cost about $218 billion. The 80 percent consumed by the 20 percent of individuals with significant health care needs would cost about $874 billion in private spending.

It is much of this $874 billion that would be transferred to the state high-risk pools under Sen. McCain’s proposal. His adviser, Douglas Holtz-Eakin, provides an “extremely preliminary” estimate of $7 billion to $10 billion in federal subsidies for these pools. Who pays the other $864 billion? The individual?

Excluding those covered by Medicare, Medicaid and other public programs, 225 million of us have private insurance or are uninsured. Twenty percent of those, or 45 million people, theoretically would be in the high-risk pool if everyone were to obtain coverage under his program. If the high-risk individuals were responsible for the remaining $864 billion, each would have to pay $19,200. Obviously, that can’t work.

Others propose that high-risk pools be funded by an assessment on commercial insurers. But that moves the financing for high-risk individuals back into the private insurance risk pools. Not only would that drive up premiums, which are already unaffordable, it would also add another layer of administrative costs in a system that is already overburdened with administrative excesses.

Now you know why state high-risk pools don’t work. There is only one reason to propose them in the first place – that is to relieve the private insurance industry of its responsibility of paying for necessary health care, merely to enhance its successful business model of selling insurance primarily to the people who don’t need care now, and hopefully won’t in the future.

As John Geyman says, the private insurance industry is dying, and we shouldn’t try to resuscitate it – certainly not if we we taxpayers are the ones who are going to be indemnifying those who actually need health care.

Message trumps policy?

How to Talk About Health Care Reform: Summary of Research on Health Care Messaging

Celinda Lake and Drew Westen
Families USA, Herndon Alliance, Westen Strategies, Lake Research Partners
May 22, 2008

If you want to see universal health care enacted, stop using that phrase.

Message development: Using focus groups of swing voters and online dial-groups

Conservative message:

Families should be in charge of their health care dollars. Rising health care costs are a problem, and the best way to bring them down is to increase competition among health care providers and put an end to these million dollar lawsuits that drive up insurance costs and put doctors out of business. The best solution to our health care problems is to let the free market work, foster more competition, and help people deal with the rising costs of coverage with health savings accounts that allow people to manage their own health care decisions. The last thing we need is the government taking over health care and creating a massive bureaucracy that will cost us billions of dollars a year. Sure, we have problems, but what the naysayers always seem to forget is that Americans still have the best health care in the world. Europe and Canada have government run health care, and their patients come here for treatment due to long waits and poor quality care. The answer to our health care problems is a freer market, not socialized medicine.
MEAN DIAL RATING (0-100) = 55

Progressive message I:

I believe that people who work for a living ought to be able to take their kids to a doctor, and people who are retired, ill, or temporarily out of work shouldn’t risk losing their life savings because of one illness. We’re not just talking about poor people. We’re talking about middle class Americans who are getting squeezed. Too many people have to think twice before switching jobs or starting a business because they’re worried they won’t be able to get insurance. We need comprehensive reform, not a band-aid. That means putting government to work for taxpayers again, not for special interests, by requiring insurance companies to put more money into patient care and less into efforts to deny it. It means preventing insurance companies from excluding patients because of “pre-existing conditions” and overriding doctors’ decisions about what their patients need. It means giving us choices among plans so we can decide what’s best for our own families, including the choice to keep our current doctor. It means limiting the amount anyone has to spend out of pocket, so no one loses their life’s savings because of a sick child or a hospital bill. And it means giving small businesses tax breaks to offset the costs of covering their employees, and requiring big businesses to offer coverage to their employees instead of sticking middle class taxpayers with the tab.
MEAN DIAL RATING (0-100) = 71

Progressive message II:

I believe in a family doctor for every family. It’s not right that hard-working Americans are struggling to afford health care and prescription drugs, while we’re strangling small businesses with the cost of their employees’ health care. The market hasn’t solved this problem, and it’s not going to as long as big insurance and drug companies are profiting at our expense. But we don’t need to replace managed care bureaucracy with government bureaucracy. We need common sense reform that gives people more choices, not less, including the choice to stay with the doctor they have now. We need to make insurance companies compete with each other to keep costs down and quality up, and give people the option to buy into the same plan members of Congress get, because if it’s good enough for Congress, it’s good enough for the people they represent. And we need government to set high standards to keep deductibles low, stop insurance companies from cherry-picking patients by excluding people with “pre-existing conditions,” and guarantee preventive care like cancer screening that cuts long-term costs and saves lives.
MEAN DIAL RATING (0-100) = 69

This link will download the Lake/Westen PowerPoint presentation, but you will be able to open it only if you have an appropriate program on your computer:
https://wadmin5.getactive.com/system/ga/redirect.jsp?redirectURL=http%3A%2F%2Fwww.familiesusa.org%2Flink-redirect.jsp%3FitemID%3D39611471%26domain%3Dfamiliesusa&hostgroupID=27078647

And…

Key Highlights from Herndon Alliance research

Celinda Lake, David Mermin, Dan Spicer
Lake Research Partners
November 15, 2007

A strong majority of voters favor Guaranteed Affordable Choice (GAC), and voters prefer it to other health care reform alternatives tested like HSAs, tax credits, or a single payer plan.

(Note: In the survey, the rhetoric of “Guaranteed Affordable Choice” was paired with the rhetoric of each of the other three options: “Health Savings Account,” “Tax Credits,” and “Single Payer.” In each pairing, Guaranteed Affordable Choice was preferred by about two-thirds of the participants, whereas each of the other options was preferred by about one-fifth. Only their rhetoric of “Guaranteed Affordable Choice” and “Single Payer” are included here since they relate to today’s message.)

Guaranteed Affordable Choice (GAC): An approach that would guarantee affordable health insurance coverage for every American with a choice of private or public plans that cover all necessary medical services, paid for by employers and individuals on a sliding scale. (64% preferred)

Single Payer (SP): A single government-financed health insurance plan for all Americans financed by tax dollars that would pay private health care providers for a comprehensive set of medical services. (22% preferred)

http://herndonalliance.org/pdf/PollingSummaryLRP-Nov07.pdf?PHPSESSID=51de02f649a54470d01f6e2a5ae6ccbb

Comment:

By Don McCanne, MD

There is currently an intensive effort within the progressive community to establish unity in support of a message on health care reform that will resonate with swing voters as well as progressives. Those driving that effort contend that the policy debate is over, and it is now time to move forward unified behind one message.

What is that message? CHOICE! “It means giving us choices among plans so we can decide what’s best for our own families,” according to the progressive message above. You’ve heard the Democratic candidates say repeatedly that “you can keep the insurance you have if that’s your choice.”

People like choice. The conservatives understand that. They contend that government programs take away your choice. Of course a single payer system allows you to choose your health care professionals, whereas the private plans supported by the conservatives take away your freedom to choose your physicians and hospitals. But what about the progressives? They are now using the framing of the conservatives! You can have your choice of health plans! But then why deal with the real issues when the rhetoric works so well?

Now let’s look at the survey data on Guaranteed Affordable Choice (GAC). When GAC was paired with Single Payer (SP), 64% preferred the rhetoric of GAC and 22% preferred the rhetoric of SP. Let’s look specifically at the rhetoric, from a policy perspective.

Both of the GAC and SP sentences flow very well, and even members of the policy community might not detect any bias at first glance. But when you study the statements, you can see several problems with the rhetoric. As mentioned, people like the word “choice.” It’s in the GAC description but not SP, even though the SP choice of physicians and hospitals is much more important than choice of health plans. GAC has a “guarantee,” but SP does not, even though SP is automatic for everyone – the ultimate guarantee. GAC is “affordable,” but SP is silent on this even though it is the model that actually is designed to be affordable. GAC has an option of a “public” plan, but SP is a “government” plan – meant as a rhetorical pejorative. GAC is paid on a “sliding scale,” but the even more equitable progressive nature of SP tax financing is not mentioned. Someone else (“employers”) are paying a large part of the GAC premium, whereas you pay your own (“taxes”) in the SP model. Even “paid for” (GAC) is a more comfortable phrase than the sterile term “financing” (SP). SP uses “providers” whereas GAC is silent and presumably uses physicians and other health care professionals. GAC has “all necessary” medical services, whereas SP has only “a comprehensive set.”

What happened here? The policy was set in advance, frozen in the model supported by the Democratic candidates. Then a message was developed to precisely coincide with that model. This was not a survey of which policies swing voters would prefer. This was a survey of what message produces a more supportive response of a model already fixed in concrete, at least fixed from the perspective of many of those supporting unity. The problem is that the policy debate is not over.

That said, the progressive community is right in one very important regard. It is time for unity. It is time for us to unite together in support of health policies that would ensure that every individual would have access to reasonably comprehensive health care services in an equitably funded system that is affordable for each and every individual and affordable for society. Unity is fragile. Trading away these principles would divide us, but by uniting behind them, we can finally get the job done.

AHIP's proposal to reduce costs

AHIP Outlines Plan to Reduce Health Care Costs by $145 Billion

America’s Health Insurance Plans (AHIP)
May 29, 2008

The U.S. could reduce total health care spending and improve the quality of patient care if the plan proposed today by America’s Health Insurance Plans (AHIP) was implemented. PricewaterhouseCoopers reviewed AHIP’s proposals and estimates and concluded that if these proposals are fully implemented, the nation’s total health care expenditures could be $145 billion lower than currently projected by the year 2015.

Principle #1: Patients and their doctors must have the information and tools they need to evaluate treatment options and make health care decisions on the basis of safety, quality and cost.

AHIP Proposal: Access to information that compares the effectiveness and cost of treatments: Give providers, patients and purchasers access to a trusted source where they can find up-to-date and objective information on which health care services are most effective and provide the best value.

Principle #2: Patients and doctors want an efficient, interconnected health care delivery system that reduces medical errors.

AHIP Proposal: Health information technology: Encourage widespread adoption of tools such as electronic health records (EHRs), personal health records (PHRs), secure e-visits with physicians, and e-prescribing.

Principle #3: Doctors and nurses need the freedom to practice medicine without worrying about frivolous lawsuits.

AHIP Proposal: Reforming the legal system: Replace the current medical liability system with a dispute resolution process consisting of an objective, independent administrative process to provide quick and fair resolution to disputes while promoting evidence-based medicine.

Principle #4: Health insurance plans are transitioning to a system that more closely aligns payments with the quality of care patients receive.

AHIP Proposal: Build health care reform around quality improvement by rewarding safety, value and effectiveness: Work for the broader adoption of value-based reimbursement mechanisms and provide consumers with more actionable information about health care value.

Principle #5: The nation must move towards a system of care that focuses on keeping people healthy, detects disease at the earliest possible stage and rewards chronic care management.

AHIP Proposal: Enhanced disease management, care coordination and prevention programs: Deploy a new generation of strategies that emphasize prevention, improve chronic care and tailor healthcare for patients to help them live longer and stay healthier.

AHIP press release
http://www.ahip.org/content/pressrelease.aspx?docid=23426

Full report: A Shared Responsibility: Advancing Toward a More Accessible, Safe, and Affordable Health Care System for America
http://www.ahip.org/content/default.aspx?docid=23427

Comment:

By Don McCanne, MD

Health care costs have become intolerable for most individuals, employers, and the government, and the prospect is that costs will continue to increase well in excess of the rate of inflation. Most current political proposals are focused on expanding coverage. Although the proposals include token programs for cost containment, most are not much more than rhetorical fluff except for the consumer-directed proposals that would make health care access even less affordable by shifting payment responsibility to patients in need of care. This is not the direction in which we should be headed.

The majority of Americans now receive their health care coverage through private health plans. While the private insurance industry has been in control for decades, they have been unable to restrain the escalation in health care costs. They understand that the viability of their industry is threatened if the issue of affordability is not adequately addressed. Let’s look at their proposal released today that theoretically would control health care spending.

Of their five proposals, the PricewaterhouseCoopers analysis shows that only three of them are projected to provide any significant savings: (2) Health information technology, (3) Medical liability reform, defensive medicine, and (5) Disease management, chronic care, prevention. How effective would these be?

Health information technology certainly can provide benefits such as increased efficiency and error reduction, but the problem of maintaining patient confidentiality within an integrated network has not been solved and may never be. Even if we did move forward with such a system, the private industry is poised to produce and control the technology for medical records and integrated systems. When you consider who the wealthiest person on earth is, it is difficult to imagine that such a system, which will certainly not be free, will reduce health care costs in the future. That technology will be expensive and it will be designed to continue to generate an enormous amount of user fees.

The direct costs of medical liability are only a very small part of our national health expenditures. If totally eliminated, it would have only a negligible impact on reducing spending. The important question is whether or not defensive medicine is wasting resources. When physicians decide to order tests to prevent lawsuits, they are not tests that couldn’t possibly provide any information that might help the patient. Most defensive medicine tests are ordered to be certain that a less likely but very real threat does not exist. These tests may be approaching the flat of the curve, but they are tests which occasionally do reveal a threat for which intervention can be effective, even life saving. Do we really want to abandon the use of lower-yield tests merely because they also happen to provide liability protection from having missed a serious disorder?

Substituting our current tort approach to malpractice with a dispute resolution process may be a good idea, but we should not expect major cost savings from that change. Currently, the overwhelming majority of medical-injury victims do not sue and never receive compensation for their injuries. If we were to establish a process in which medical injury is automatically compensated, it is likely that it would be considered to be an entitlement program, much like workers compensation. Imagine the costs of a program in which almost all medical injury is compensated. Even if it’s a good idea, based on the number of individuals to be compensated, it would increase rather than decrease health care costs.

Much has been written about disease management, chronic care, and prevention. Appropriate disease management and chronic care should be provided by our primary care professionals rather than by wasteful third-party administrators. An advantage of introducing processes that improve care is that ongoing needs for diagnostic and therapeutic interventions are more readily identified and acted upon. Prior studies have shown that even people with the best of care are not receiving all of the services that they should be. Improving care by providing these additional, appropriate services will not reduce costs, it will increase costs.

Prevention is important, but most important preventive measures fall outside of the realm of the health care delivery system. Even AHIP states that recommended steps include the “development of a national approach to consumer education and physical fitness, leading with a national discussion aiming to develop new strategies to promote early intervention of preventable disease.”

The insurance industry’s proposals to make health care affordable will more likely increase costs, so we should ask ourselves if they really provide us with any services that actually are of value. In this report they list services that they say are worth the extra cost that we pay over and above the publicly-administered Medicare program. According to AHIP, in contrast to Medicare, “private insurers develop a range of products, sell them to an under-65 population, develop and support provider networks, promote wellness and prevention, offer disease management services, access to health information, and offer consumer support services related to choice of providers and treatment plans.”

Well let’s break this out. They “develop a range of products,” which means that they market undesirable products that reduce benefits and increase cost sharing – measures that make access to health care less affordable. They sell their products to the “under-65 population,” certainly a healthier population than those over 65, but does that mean that we should be paying more for these marketing services that Medicare doesn’t face? They “develop and support provider networks,” which take away your freedom to choose your hospitals and health care professionals. They “promote wellness and prevention,” but who doesn’t? They “offer disease management services,” which are a costly administrative intrusion into primary care. They provide “access to health information,” as if they haven’t heard of the Internet. They “offer consumer support services related to choice of providers and treatment plans,” which are decisions to be made by patients and their health care professionals, not by an intrusive private bureaucracy.

So AHIP is attempting to legitimize the continued existence of the private health insurance industry by proposing cost containment measures that can’t work, and by trying to convince us that their expensive, detrimental administrative services are worth the extra we are paying. Why should we be paying extra for services that make affordability and access worse?

This report from AHIP is a desperate attempt to convince us that the worthless services of the private insurance industry somehow provide us with value. John Geyman is right. The insurance industry is in its death throes, and we should not attempt to resuscitate it.

John Geyman, “Do Not Resuscitate:”
http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

Insurers don't like to 'share'

Dr. Susanne King
Berkshire Eagle, MA
Saturday, May 24

The current mantra of those who support our private insurance model for health care is “shared responsibility.” Their goal is to ratchet up the amount that individuals will have to pay for medical costs, by buying insurance policies that have higher deductibles, larger co-payments, and higher costs for prescription drugs. What “shared responsibility” is about is maintaining insurance company profits.

Under pressure from Wall Street for disappointing earnings during the first quarter of 2008, CEOs from the two largest health insurance plans, United Health Group and Wellpoint, told investors last week that they would “continue to protect their (profit) margins” and “not sacrifice profitability for membership” i.e., they aren’t going to hold down premium increases to keep members on their rolls. Wellpoint’s CEO, Angela Braly, also said that her company’s market power would give it the ability to lean hard on its network doctors to accept lower reimbursements. What she didn’t add was that her predecessor, retired CEO Larry Glasscock, left Wellpoint in 2007 with a $23.9 million farewell package. The private insurance model benefits neither patients nor doctors.

The truth is that when we examine who ultimately pays for health care, it is neither employers nor the government, but the individual. Employed individuals are paying for employer-sponsored health insurance plans rather than getting wage increases. Employees pay out-of pocket expenses for their share of premiums and health care costs that aren’t covered by insurance. And employed individuals also pay taxes to the government. We, as working people, provide the financial support for our current private insurance-based system.

Meanwhile, insurance companies aren’t working for us. They are busy working for their investors, and distributing our hard-earned dollars to them, as well as stoking the fortunes of their CEOs, like Wellpoint’s retired CEO Glasscock.

If we had a single-payer health care system, a national health insurance system that covered everyone and was administered by the government, there would truly be shared responsibility. The system would be funded by a modest tax on earnings, which would be an affordable, progressive tax. National health insurance would be real insurance, in which everyone is covered and the risk is distributed across the entire group, rather than the cherry-picking of healthy, working individuals that now occurs with private insurance. Everyone would have access to medical care. Coverage would be comprehensive, and would include medical care, dental care, mental health care, medications, and long term care. Patients could choose their own doctors and hospitals. There would be no co-payments or deductibles, and no denials or hidden costs when a patient needed his insurance.

Polls show that the majority of people support national health insurance. The obstacle to health care reform is corporate special interests that profit from the current health care system, and their tenacious grip on the political process, through their lobbying efforts and political donations. This leads some to say that significant health care reform, like replacing our private health insurance system with national single-payer health insurance, is not politically feasible.

But there is a growing grassroots movement for single payer health care. More and more doctors are joining the organization Physicians for a National Health Program (www.pnhp). There is legislation at the federal level for a national health insurance program, HR 676, currently sponsored by 90 legislators, including Rep. John Olver and seven other representatives from Massachusetts.

Recently, in his New York Times column, Thomas Friedman wrote this about his mother and her perseverance. Every time life knocked her down, she got up, dusted herself off, and kept marching forward, motivated by the saying that pessimists are usually right, optimists are usually wrong, but most great changes were made by optimists. Health care reform activists are optimistic and marching forward; please join us to reform the health care system.

Susanne L. King, M.D., is a Lenox practitioner.