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The Morning Consult, May 20, 2014

As the health insurance industry increasingly looks to market directly to consumers for new revenue, legacy brand challenges remain.  The words “greedy”, “money”, “expensive”, and “profit” dominated voter responses when asked to identify what comes to mind when you think of health insurance companies.

This puts insurers in a precarious position with respect to the Affordable Care Act’s health insurance exchanges should health plans choose to raise premiums next year during open enrollment.  Brand connotations will also impact investment decisions as some insurers look to acquire hospitals and physician practices or diversify into consumer-facing health IT products. The following word clouds illustrate the 100 most frequently given responses.

In a word or two, could you please tell me what comes to mind when you think of health insurance companies?

ARE PHARMACEUTICAL COMPANIES LOSING THEIR INNOVATION BRANDING?

In a year defined by mergers and acquisitions, the pharmaceutical industry increasingly faces a public branding challenge.  The words “greedy”, “money”, “expensive”, and “profit” are seen as most identifiable with pharmaceutical drug companies.

Notably absent from responses is the word “innovation”.  The scientific breakthroughs of the blockbuster drug era had at one time placed the pharmaceutical industry top of mind among the most innovative industries for most Americans.  As the pharmaceutical industry continues to reorganize, and in some cases relocate, it will be critical to watch if a new era of personalized medicine and drug innovation can reshape brand impressions among an aging American public.

In a word or two, could you please tell me what comes to mind when you think of pharmaceutical drug companies?

MEDICAL DEVICE COMPANIES DRAW POSITIVE AND CRITICAL REVIEWS

Like other for-profit industry sectors, medical device companies draw critical reactions like “expensive” and “greedy”, but overall the industry draws the most positive praise as well with notable brand attributes like “good”, “innovative”, and “helpful”.

The positive brand attributes stand out as the medical device companies have been among the most active healthcare stakeholders in Washington with repeated attempts to repeal the Affordable Care Act’s excise tax on medical device revenue.

In a word or two, could you please tell me what comes to mind when you think of medical device companies?

HOSPITALS STAND AT THE CROSSROADS OF “EXPENSIVE” AND “GOOD”

As health system consolidation increases, hospitals stand at crossroads with respect to brand impressions.  Negative connotations like “expensive” and “money” stand in stark contrast to “good” and “necessary”.

Increased public focus on price transparency and chargemasters raises negative brand connotations. At the same time, many hospitals are looking to leverage the “good” and “caring” elements of their brands by acquiring physician practices and exploring running their own insurance products.

In a word or two, could you please tell me what comes to mind when you think of hospitals?

DOCS ARE “GOOD” “CARING” AND “PROFESSIONAL” BUT MAYBE “OVERPAID”

Physicians remain widely respected with strong brand attributes.  Words like “good”, “caring”, “professional” and “dedicated” stand out among a majority of positive impressions.  The only negative connotations that appear among the American public include “overpaid” and “expensive”.  As more and more physicians chose hospital employment over private practice, we will be watching to see if these brand attributes change or remain the same.

In a word or two, could you please tell me what comes to mind when you think of doctors?

NURSES ARE THE HEALTHCARE GOLD STANDARD

Nowhere in the healthcare industry is the American public more in agreement than when it comes to nurses.  There isn’t a single negative brand impression associated with nurses among the top 100 most frequent responses.  The issues of being “underpaid” and “overworked” may have implications in a number of states as nursing unions pursue multiple ballot initiatives and state governments consider reforms to long standing scope of practice laws.

In a word or two, could you please tell me what comes to mind when you think of nurses?

AMERICANS LOVE MEDICARE

The potency of Medicare politics is evident when you consider just how strong the brand attributions are for the program.  Worlds like “necessary”, “good”, and “helpful” overshadow even the faintest recognition that the program may be “underfunded”.  If Washington is to take on Medicare reform in earnest, a substantial education and branding effort will be required to convince Americans that the program needs to be changed.

In a word or two, could you please tell me what comes to mind when you think of Medicare?

MEDICAID SEEN AS NEEDED BUT DRAWS MIXED REVIEWS

The American public overwhelmingly identifies Medicaid as being “needed” and “good”, but compared to Medicare, more negative connotations like “fraud”, “wasteful”, and “abused” are registered.  This in part colors the ongoing state debates over whether to expand the Medicaid program as part of the Affordable Care Act.

In a word or two, could you please tell me what comes to mind when you think of Medicaid?

• Topline results

http://www.themorningconsult.com/2014/05/poll-americans-associate-health-industry-with-high-costs/

By Aaron Carroll, M.D.
The Week, May 19, 2014

In the U.S., we throw around the phrase “socialized medicine” a lot, typically referring to a Medicare-for-all system like Canada’s. But when you think about it, a single-payer insurance system leaves the whole medical industry out of the government orbit.

Enter the U.K.’s National Health Service. When it comes to socialized medicine, this is the real deal. Not only is almost all coverage provided as a public service, most hospitals are run by the NHS, where doctors work for the government: It’s single-payer and single-provider (with some exceptions). How well does it work? Aaron Carroll explains below. –Ryan Cooper

http://theweek.com/article/index/261777/britain-shows-how-real-socialized-medicine-works

A presentation by Dr. Andrew Coates

Labor Beat, May 16, 2014

On YouTube at: http://youtu.be/_M4sP6FieEk

This video provides a clear overview of the national health care crisis, the inadequacies of Obamacare, and the argument for an ‘everybody in, nobody out’ single-payer health program. Andrew D. Coates, M.D., gives a motivating presentation of the basics in this debate, backed up by selected PowerPoint graphics prepared by Physicians for a National Health Program (PNHP) and the Illinois Single-Payer Coalition. 

Dr. Coates has many titles (President, PNHP; Clinical Assistant Professor of Medicine and Assistant Professor of Psychiatry, Albany Medical College; Chief of Hospital Medicine, Samaritan Hospital, Troy, NY; Medical Director, Albany County Nursing Home). The talk was recorded at Access Living in Chicago on May 8, 2014.

Dr. Coates concludes that insurers are selling an “unaffordable, defective product” as he compares the U.S. health care system to other industrialized countries. We are a nation of uninsured and increasingly under-insured, facing staggering household debt from medical bills, and in particular exposing under-insured children, women, minorities and retirees to increasing fatality rates and poor health, in order to satisfy a market solution to health care.

He points to the 2013 AFL-CIO resolution’s “commitment to pursue health care for all ultimately through a single-payer system” as an important step forward. 

Dr. Coates calls upon the union movement: “I think that for the trade union movement that if we speak out for what it means for all working people we’re talking about liberating the whole country here with basic economic rights, the right to necessary care. Then we find a way forward for the whole trade union movement. The unions they have the expertise, they know how to lead us forward, they know exactly how to organize people, how to fight … and it’s going to take a fight. There’s no shortcut.”

Length – 25:52

Besides YouTube, this video is also archived at laborbeat.org. It will be broadcast on Chicago Access Network Television.

By Elisabeth Rosenthal
The New York Times, May 17, 2014

Though the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.

That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.

The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.

The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.

“At large hospitals there are senior V.P.s, V.P.s of this, that and the other,” said Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on health care. “Each one of them is paid more than before, and more than in any other country.”

She added, “The pay for the top five or 10 executives at insurers is pretty astounding — way more than a highly trained surgeon.”

She said that executive salaries in health care “increased hugely in the ‘90s” and that the trend has continued. For example, in addition to Mr. Del Mauro’s $21.7 million package, Barnabas Health listed more than 20 vice presidents who earned over $350,000 on its latest available tax return; the new chief executive earned about $3 million. Data released by Medicare show that Barnabas Health’s hospitals bill more than twice the national average for many procedures. (In 2006, the hospital paid one of the largest Medicare fines ever to settle fraud charges brought by federal prosecutors.)

Hospitals and insurers maintain that large pay packages are necessary to attract top executives who have the expertise needed to cope with the complex structure of American health care, where hospitals and insurers undertake hundreds of negotiations to set prices.

Ellen Greene, a spokeswoman for Barnabas Health, said Mr. Del Mauro’s retirement package was “a function of over four decades of service and reflects his exceptional legacy.” Nearly $14 million was a cumulative payout from a deferred retirement plan, she said, and the remainder included base compensation, a bonus and an incentive plan

Ms. Greene also said Barnabas’s compensation program follows I.R.S. rules and is established by an executive compensation committee with “guidance from a nationally recognized compensation consultant.”

And studies suggest that administrative costs make up 20 to 30 percent of the United States health care bill, far higher than in any other country. American insurers, meanwhile, spent $606 per person on administrative costs, more than twice as much as in any other developed country and more than three times as much as many, according to a study by the Commonwealth Fund.

As a result of the system’s complexity, there are many jobs descriptions for positions that often don’t exist elsewhere: medical coders, claims adjusters, medical device brokers, drug purchasers — not to mention the “navigators” created by the Affordable Care Act.

Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services.

“Most doctors want to do well by their patients,” said Dr. Abeel A. Mangi, a cardiothoracic surgeon at the Yale School of Medicine, who is teaming up with a group at the Yale School of Management to better evaluate cost and outcomes in his department. “Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective.”

Doctors are beginning to push back: Last month, 75 doctors in northern Wisconsin took out an advertisement in The Wisconsin State Journal demanding widespread health reforms to lower prices, including penalizing hospitals for overbuilding and requiring that 95 percent of insurance premiums be used on medical care. The movement was ignited when a surgeon, Dr. Hans Rechsteiner, discovered that a brief outpatient appendectomy he had performed for a fee of $1,700 generated over $12,000 in hospital bills, including $6,500 for operating room and recovery room charges.

It’s worth noting that the health care industry is staffed by some of the lowest as well as highest paid professionals in any business. The average staff nurse is paid about $61,000 a year, and an emergency medical technician earns just about minimum wage, for a yearly income of $27,000, according to the Compdata analysis. Many medics work two or three jobs to make ends meet.

“It’s stressful, dirty, hard work, and the burnout rate is high,” said Tom McNulty, a 19-year-old college student who volunteers for an ambulance corps outside Rochester. Though he finds it fulfilling, he said he would not make it a career: “Financially, it’s not feasible.”

Elisabeth Rosenthal is a reporter for The New York Times who is writing a series about the cost of health care, “Paying Till It Hurts.” A version of this news analysis appears in print on May 18, 2014, on page SR4 of the New York edition with the headline: Doctor’s Salaries Are Not the Big Cost.

‘This new rule to limit payments for needed medical procedures is a reminder of everything that is wrong with our profit-driven healthcare system.’

By Sarah Lazare
Common Dreams, May 16, 2014

The Obama administration earlier this month quietly handed the insurance industry another loophole in the Affordable Care Act—infuriating advocates for universal coverage who say this shows that an insurance-driven health system is doomed to fail.

Announced on May 2, the provision opens the door to “reference pricing,” which allows insurance companies to set a price for medical procedures. If a patient receives a treatment that costs more, he/she will simply have to pay out of pocket. The measure is slated to apply to a majority of work-based health insurance plans and exchanges under the Affordable Care Act (also known as “Obamacare”), according to the Associated Press.

Many worry that reference pricing will force patients to bear the burden of a costly and difficult-to-navigate medical system.

“We don’t need reference pricing—we need ‘right pricing’ under a single-payer program,” Don McCanne, M.D., senior health policy fellow at Physicians for a National Health Program told Common Dreams. “This is merely another way in which insurance companies are going to chisel down payment for care, shifting a greater share of the cost onto patients.”

“This new rule to limit payments for needed medical procedures is a reminder of everything that is wrong with our profit-driven healthcare system,” Jean Ross, RN, co-president of National Nurses United, told Common Dreams. “Rather than crack down on price gouging by hospitals—some of who set their charges as high as 12 times their costs — the administration is enacting a rule to ration care for patients.”

Critics charge that the ruling even violates one of the Affordable Care Act’s key tenets: To end “lifetime and yearly dollar limits on coverage of essential health benefits.”

In its own fact sheet, the Department of Labor acknowledges concerns that “such a pricing structure may be a subterfuge for the imposition of otherwise prohibited limitations on coverage, without ensuring access to quality care and an adequate network of providers.”

According to Ross, “A Commonwealth Fund study last November comparing Americans to 10 other developed countries found that U.S. adults are by far the most likely to not get the treatment their doctor recommends, as well as forgoing doctor visits or filling prescriptions, because of the high cost. All that this rule will do is increase those medical disparities and further brand our dysfunctional healthcare system as one based on ability to pay rather than on patient need.”

Sarah Lazare is writer at Common Dreams.

https://www.commondreams.org/headline/2014/05/16-4

GOP pols quietly changing Medicaid expansion to system of various right-wing schemes. Here’s why lives are at stake

By Adam Gaffney, M.D.
Salon, May 15, 2014

Imagine you’re a conservative state politician ideologically opposed to government-provided health insurance for those with low incomes, but you nonetheless recognize the folly in forgoing billions of dollars in federal funds available to states that expand Medicaid simply to prove a Dickensian point (of questionable popularity).

It turns out that you can take the money, expand but also partially privatize Medicaid in your state, scrap some of its benefits, funnel a piece of the cash to the insurance industry, create new co-payments to make life a bit harder for those who happen to be both sick and broke, and even teach the poor a lesson or two about the value of health, wealth and weight loss, to boot!

In a concerning new trend, states around the country are pursuing a so-called private option to the Affordable Care Act’s Medicaid expansion, changing it to a system of “premium support” inclusive of various conservative “innovative solutions.” Other states, meanwhile, are maintaining traditional Medicaid but adding unprecedented forms of cost sharing. In doing so, even as they begrudgingly accept Medicaid’s expansion, these states – largely under the control of Republican governors, legislatures or both – are historically reshaping the program. The price of their “innovation” will – predictably – be paid by those living in (or near) poverty.

First, how did this “private option” emerge? The ACA was written to expand Medicaid to everyone in the country earning less than 138 percent of the federal poverty level.  This expansion is fully funded by the federal government until 2016, after which its contribution decreases (though to no less than 90 percent). However, in June 2012 the Supreme Court ruled that though the individual mandate was constitutional, the federal government couldn’t require states to expand their Medicaid programs; ever since, the Medicaid expansion has been hotly contested in state after state. Though 26 states have so far chosen to expand healthcare for low-income adults, the remaining 24 (mostly red) states have refused (or are still debating) the expansion.

But apart from the states that have flatly rejected the Medicaid expansion (which would have happened almost entirely on the federal government’s dime), many other states are using their newfound leverage to take the money and run (in a conservative direction). And the administration – eager to maximize the scope of the expansion – has been willing to compromise.

Arkansas was the first state to win a federal waiver to create a “private option” as a “compromise” to the Medicaid expansion. Rather than enroll the newly eligible into the traditional Medicaid program, Arkansas will instead use federal money to help those with low income buy private health plans, analogous to the concept of “premium support” that Paul Ryan is perpetually pushing for Medicare. More recently, in December, Iowa became the second state to win a private option waiver from the Centers for Medicare and Medicaid Services. Many other states – ranging from Pennsylvania to New Hampshire to Utah – are seeking to follow suit.

Now, private health insurance has consistently been found to be more expensive than public programs, so it’s clear that a consideration for costs has little to do with this strategy. The specifics of the waivers, however, which strip benefits and raise co-pays, more clearly elucidate the purpose of the private option.

Take Iowa, which used its waiver to exclude coverage of some traditional Medicaid benefits, like nonemergency medical transportation (at least for one year, after which CMS has required that it study the results). Now it might not seem obvious why a health insurance program should cover such transportation (most don’t), unless we appreciate the minimal resources and frequently complex medical needs of many of those who rely on Medicaid.

It’s simply unrealistic for individuals who have minimal or no disposable income, who may have multiple chronic illnesses or mental health problems, to coordinate and fund transportation to their innumerable treatments, tests, office visits, outpatient procedures, and so forth. According to a recent survey, for instance, of those using Medicaid-funded transportation, almost a thirdwere attending behavioral health or substance abuse treatment, while another 18 percent needed it to make it to dialysis. In fact, in the case Smith v. Vowell, a federal court went so far as to findthat Texas’ “deprivation of medically necessary transportation” to patients receiving public healthcare benefits was neither “therapeutic, practical, nor legal.” The Iowa state government nonetheless felt the need to take a brave stand against this important program (even though it would’ve paid nothing for it upfront, and a small fraction indefinitely in the future).

What else is “innovative” about private option Medicaid? One commonality among the proposals is the introduction of new co-payments for Medicaid enrollees, for such things like office visits and prescriptions. In the case of Iowa and Arkansas, these co-payments can amount to 5 percent of annual income. The sicker you are, of course, the more you’ll need to spend, which apparently – for some lawmakers – makes perfect sense. Iowa, Pennsylvania and Michigan are also enthused about charging for “nonemergency” use of the emergency room, which amounts to a $50 fee in the case of Michigan.

Now, presumably, the point of such fees is to punish those hypothetical individuals who, for unclear reasons, purposefully scam Medicaid by wasting days at a time sitting in E.R.s, despite knowing that they are perfectly well and sound. Could there be a flaw in such reasoning, however? After all, I (like most physicians) have sent patients to the E.R. for what sounded like concerning symptoms over the phone (or even from clinic), who ultimately didn’t require admission to the hospital. Clearly, physicians can’t perfectly predict who actually “needs” the E.R., though apparently our patients with low income must quickly learn how to – or otherwise pay a price (or, even worse, avoid the E.R. altogether, even when they might actually need it).

Now such “cost sharing” represents “largely uncharted territory” for Medicaid, as an article in the New England Journal of Medicine recently put it – and for a good reason. For though these fees and co-payments may be pocket change to the well-paid legislators who created them (many of whom will later leverage their purported “public service” into lucrative careers in lobbying or industry), for those living in poverty, these quantities of money mean a great deal. At the very least, such co-payments create a strong disincentive to use healthcare, to fill prescriptions, to see their doctor, or even to sign up for Medicaid to begin with.

However, perhaps even more obnoxious – if not quite as deleterious – are the so-called Wellness Programs that the private option programs create. For instance, the “Iowa Health and Wellness Plan” not only creates co-payments at point of use, but also charges enrollees a monthly premium, which they can offset by earning “rewards” through engaging in “healthy behaviors.” “In the new plans,” a recent white paper from the Iowa state government proclaims, “members have a financial stake in their healthcare. The waivers are designed to drive appropriate consumer behavior in their use of the health care system.”

It’s obviously not enough that the chronically ill living below or near the poverty level have their lives on the line: We must teach them to be better healthcare consumers. But how can we drive such individuals (who apparently care nothing for health for health’s sake) toward “appropriate consumer behavior”? Well, it’s complicated. According to the white paper, enrollees should work to earn “rewards” to offset their monthly premiums by completing various health-related tasks. These rewards may either be “basic” or “enhanced,” depending on the “level or milestone achieved.”

For instance, “accomplishing a weight loss of 5 percent may result in an ‘enhanced’ reward of an additional $50.” This $50 can then be used to pay down the premium that private option Medicaid itself created. I should point out that there is no support for such programs in the medical literature; a review in the health policy journal Health Affairs last year concluded that “evidence is sparse that financial incentives induce behavior that improves health,” whether with respect to losing weight or quitting smoking. Even putting aside the empiric evidence, however, it’s surprising that anyone would even think otherwise: nicotine is so addictive that it can surmount the concerns of entirely reasonable and intelligent people about lung cancer, emphysema, stroke, heart attacks, and death. Does anyone really think that a $25 gift card will be a game changer? In any event (as most of us among the imperfect can attest), it’s quite hard to quit unhealthy habits or lose weight, even when one is financially secure; under severe financial, physical or psychological stress or strain, it’s that much harder. Imposing a fee and then requiring various behavioral changes (say, weight loss) to offset this fee is not all that different than directly penalizing those with low income for, say, being overweight. That may bring a smile to the face of some; I find it petty and unproductive.

In other words, between privatization, co-pays, cutbacks in important benefits, and these silly “wellness” programs, the private option somehow manages to combine the worst aspects of “liberal” public health paternalism, neoliberal healthcare consumerism, and conservative anti-welfarism.  What’s not to like?

In sum, the waivers already won have allowed federal Medicaid dollars to flow into private insurance companies; have initiated the rollback of traditional Medicaid services like medical transportation; have facilitated the introduction of co-payments and premiums for people who have almost no money; and have introduced repugnant “wellness programs” that allegedly “drive appropriate consumer behavior” toward health. But these programs might even have a moral purpose!  Pennsylvania, for instance, is reportedly working not only to eliminate coverage for transportation, but also to waive the requirement that it pay for contraceptives and the implantation of intrauterine devices for Medicaid patients. While the administration will hopefully have the good sense to send such nonsense back to the Keystone State, I believe they’ve already conceded too much.

“Programs for poor people,” goes an old aphorism, “are poor programs.” With respect to a means-tested program such as Medicaid, there is no doubt truth in this. As compared to Medicare or private insurance, patients with Medicaid can face serious hurdles in accessing the healthcare system, whatever their benefits on paper. Of course, to address such a disparity, we would need a universal single-payer healthcare system for all. Before we achieve that, however, Medicaid is what those with low-incomes rely on. The refusal of half the states in the country to expand Medicaid could cause, at least by one estimate, in excess of 7,000 deaths. Meanwhile, as I’ve explored here, other states are seeking to convert the public Medicaid program into a system of premium support bereft of important benefits and full of new charges and paternalistic “rewards.”

Those with low incomes (and, in point of fact, most of those with middle incomes as well) have been essentially excluded from benefiting from the last three decades of economic growth, while a tiny sliver of the country has prospered enormously. Providing adequate health insurance, without co-payments and with important benefits like transportation, is the least that they deserve. Now some might say that whatever the problems with the private option, some healthcare is better than none. That may very well be true, but it doesn’t mean taking it with a smile – or without a fight.

AG is a physician and writer in Massachusetts.  He blogs at www.theprogressivephysician.org and is on twitter at @awgaffney.

http://www.salon.com/2014/05/15/conservatives%E2%80%99_awful_new_medicaid_ploy_the_obamacare_%E2%80%9Cprivate_option%E2%80%9D/

By Philip Caper, M.D.
Bangor Daily News, May 15, 2014

Opponents of universal health care often claim that in order to afford it we will have to ration health care. My response to that old shibboleth is that we already pay more than enough to cover everybody, and that we already ration health care, as we must in a world of finite financial and real resources. The real question is not, “Should we ration health care?” but rather, “What’s the fairest way to do it?”

In all other wealthy countries, where everybody has a right to health care, rationing is done on the basis of medical need. The more urgent the need, the sooner care is provided. Urgent care is provided promptly, and less urgent care may be put off for awhile.

In many cases, delaying care is actually a good thing. There is a growing recognition that in the U.S. some types of care are too accessible, resulting in costly and risky overuse of many tests and treatments that have little or no value, and others that may actually do more harm than good.

In exchange for restricting access to some tests or treatments of little or no value, we could reduce overall health care costs significantly and largely eliminate cost as a factor in deciding who receives medical care and what kind of care they receive. In most other wealthy countries, the ability to pay does not enter into the thinking of either the patient or the doctor.

The U.S. is unique among wealthy countries in using ability to pay as a means of rationing medical care. The results are often devastating. A recent Commonwealth Fund study found that in states where the number of uninsured is highest, rates of deaths from treatable illnesses are also highest. Another recent study in Massachusetts concluded that morbidity and mortality from treatable illness declined significantly after 2006, when health care reform expanded coverage there.

I’m in favor of expanding health care coverage to everybody and rationing through overall budgetary constraints rather than simply pricing some people out of the system. While some with good coverage receive too much medical care, others without coverage receive too little and may wait forever for needed care.

People who face financial barriers to accessing health care often put off beneficial primary care, only to later require care for more serious and expensive illness. Those costs end up being paid by all the rest of us.

Medical tests, procedures and treatments have their benefits, but they also have their downsides. Drugs have side effects, tests and procedures have risks, and all have economic costs. If we agree to limit access to ineffective, marginally effective or downright harmful care, we could more than afford to expand access to everybody.

In many instances, our aggressive, anything-goes style of medicine has caused more harm than good. Mammography and PSA tests for prostate cancer are recent examples. Over 65 medical specialty societies have each recently identified at least five such tests or procedures.

According to a recent study by the Institute of Medicine, we waste over $340 billion a year on unnecessary and inefficiently delivered services. That’s more than enough to extend coverage to everybody.

I believe most Americans would willingly give up something they may want but don’t really, urgently need if it meant a neighbor who needed it more could have it instead. I’ve seen that happen many times here in Maine. But we seem to have a lot of trouble turning our generous neighborly spirit into public policy.

So why don’t we make our means-tested system of rationing more rational, and, like other wealthy countries, base it on medical need rather than financial means? Not only would our health care system become less costly and more efficient as a result, but it would also become more humane.

Such a change would allow doctors to treat patients the way our training and professional ethics encourage and our Hippocratic Oath demands.

And it would make our country yet a better place to live.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2014/05/15/health/should-health-care-be-rationed-it-already-is/