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By Carmen Chai
Global News (Canada), March 13, 2014

TORONTO – Dr. Danielle Martin knows Canadians are proud of the country’s universal health care. She is too.

At a U.S. Senate subcommittee earlier this week, the Toronto family doctor laid the smack down on American officials who alleged that doctors and patients were fleeing Canada for greener pastures in the U.S.

Martin knew she had to stand her ground. But she didn’t expect the overwhelming response from Canadians who are now applauding how she handled the heated exchange.

So far, she’s been hailed as a national hero for “schooling” the U.S. Senate.

“I think it taps into a really deep pride that Canadians have about single payer health care. I don’t think it’s about me. The basic value that Canadians hold that access to health care should be based on need and not ability to pay is very fundamental to how people view themselves as Canadians,” Martin told Global News on Thursday morning.

“We see our health care system get misrepresented and trashed in the American media as part of their debate quite a lot and that’s a source of real frustration for Canadians,” she said.

The Women’s College Hospital doctor was invited by senators to Washington for a panel on what the U.S. can learn from other countries that function on a single payer health care system. Martin joined a panel of international experts on single payer health care models – doctors from Denmark, France, and Taiwan also shed light on the system.

It was during the question-and-answer period when Martin and Republican Senator Richard Burr began their verbal sparring.

“On average, how many Canadian patients on a waiting list die each year? Do you know?” Burr asked.

“I don’t, sir, but I know that there are 45,000 in American who die waiting because they don’t have insurance at all,” she said.

“What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?” Burr asked. He was referring to Newfoundland Premier Danny Williams’ decision to head to Miami for heart surgery in 2010.

“It’s actually interesting because, in fact, the people who are the pioneers of that particular surgery…are in Toronto, at the Peter Munk Cardiac Centre, just down the street from where I work,” Martin quipped back.

Finally, when Burr asked why Canadian doctors are leaving the public system, Martin shot down his claim: “In fact, we see a net influx of physicians from the United States into the Canadian system over the last number of years,” she said.

But Martin wants Canadians to know: as much as it might look like it, the meeting was respectful and the senators graciously welcomed the panelists.

“People have strong opinions about this so it was clear there were clashing views but I certainly didn’t find the tone disrespectful,” Martin told Global News.

She knows a single committee meeting wouldn’t suddenly sway U.S. health officials into considering the Canadian health care model, but Martin said she’s “thrilled” that the exchange has people talking.

“It means this kind of hearing isn’t just political theatre. It serves a social function to get a conversation going and that’s really important,” she said.

So far, she’s received emails and phone calls about her appearance at the Senate meeting. Some people have even written to her to say that they ended up watching the entire 90-minute meeting because they were so enthralled.

Doctor who schooled U.S. senator ‘thrilled’ by Canadian support

PNHP note: For additional Canadian coverage of Dr. Danielle Martin’s testimony, see this story by CBC News:
http://www.cbc.ca/news/world/dr-danielle-martin-gives-washington-a-lesson-on-canadian-health-care-1.2570872

By Michael Hiltzik
The Los Angeles Times, March 12, 2014

A U.S. politician’s I-don’t-need-no-stinkin’-facts approach to health policy ran smack into some of those troublesome facts Tuesday at a Senate hearing on single-payer healthcare, as it’s practiced in Canada and several other countries.

The countries in question have successful and popular government-sponsored single-payer systems, provide universal coverage and match or outdo the United States on numerous measures of medical outcomes — for far less money than the U.S. spends. To explain this, Sen. Bernie Sanders (I-Vt.) asked seven experts to testify before his subcommittee on primary health and aging.

Those interested in how the U.S. matches up should watch the whole 90-minute session. (The official subcommittee hearing record is available.)

By far the high point of the morning was an exchange between Sen. Richard Burr (R-N.C.) and Danielle Martin, a physician and health policy professor from Toronto. The exchange, in which Martin bats down the myths and misunderstandings about the Canadian system that Burr throws at her, starts at about the 1:08:15 mark.

(The reference to “Premier Williams” is to Newfoundland Premier Danny Williams, whose decision to have a heart valve procedure in Miami, near where he owns a condo, rather than Canada, is widely viewed in Canada as a rich man’s failure to investigate the care available to him closer to home.)

Here’s a lightly edited transcript of the key moments, which start with Burr asking Martin about the observation in her written testimony that wait times for elective surgery in single-payer systems will lengthen as doctors move out of the public system:

BURR: Why are doctors exiting the public system in Canada?

MARTIN: Thank you for your question, Senator. If I didn’t express myself in a way to make myself understood, I apologize. There are no doctors exiting the public system in Canada, and in fact we see a net influx of physicians from the United States into the Canadian system over the last number of years.

What I did say was that the solution to the wait time challenge that we have in Canada — we do have a difficult time with waits for elective medical procedures — does not lie in moving away from our single-payer system toward a multipayer system. And that’s borne out by the experience of Australia. So Australia used to have a single-tier system and did in the 1990s move toward a multiple-payer system where private insurance was permitted. And a very well-known study by Duckett, et al., tracked what took place in terms of wait times in Australia as the multipayer system was put in place.

And what they found was in those areas of Australia where private insurance was being taken up and utilized, waits in the public system became longer. 

BURR: What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?

MARTIN: It’s actually interesting, because in fact the people who are the pioneers of that particular surgery, which Premier Williams had, and have the best health outcomes in the world for that surgery, are in Toronto, at the Peter Munk Cardiac Center, just down the street from where I work.

So what I say is that sometimes people have a perception, and I believe that actually this is fueled in part by media discourse, that going to where you pay more for something, that that necessarily makes it better, but it’s not actually borne out by the evidence on outcomes from that cardiac surgery or any other.

(The ultimate zinger came at the end of the exchange, when Burr thought he had Martin down for the count about wait times in Canada, and she neatly put the difference between the Canadian and U.S. systems in perspective.)

BURR: On average, how many Canadian patients on a waiting list die each year? Do you know?

MARTIN: I don’t, sir, but I know that there are 45,000 in America who die waiting because they don’t have insurance at all.

http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story#ixzz2vmQDiy2b

By Mark Karlin
Truthout/Buzzflash, March 11, 2014

Here are two basic facts to remember about the health care system in the United States. First, there is the high cost, as noted in a 2012 report on PBS:

How much is good health care worth to you? $8,233 per year? That’s how much the U.S. spends per person.

Worth it?

That figure is more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom. On a more global scale, it means U.S. health care costs now eat up 17.6 percent of GDP….

Whether measured relative to its population or its economy, the United States spends by far the most in the world on health care.

The U.S. spent $8,233 on health per person in 2010. Norway, the Netherlands and Switzerland are the next highest spenders, but in the same year, they all spent at least $3,000 less per person. The average spending on health care among the other 33 developed OECD countries was $3,268 per person.

That statistic brings up the much-beloved free market criteria of return on investment (ROI), at which the US performs abysmally according to many studies when it comes to health. 

An NPR article in 2013 is entitled, “US Ranks Below 16 Other Rich Countries In Health Report”:

It’s no news that the U.S. has lower life expectancy and higher infant mortality than most high-income countries. But a … new report says Americans are actually less healthy across their entire life spans than citizens of 16 other wealthy nations.

And the gap is steadily widening.

“What struck us — and it was quite sobering — was the recurring trend in which the U.S. seems to be slipping behind other high-income countries,” the lead author of the report, Dr. Steven Woolf, tells Shots.

He says Americans of all ages up to 75 have shorter lives and more illness and injury.

It should be noted that in this report, the United States is being compared to other “developed” nations.  A recent United Nations Population Divison report ranked the US 40th in life expectancy among all nations in 2010.

In short, the US spends the most on medical care with poor life expectancy results, even including many nations that are not considered wealthy.

The Affordable Care Act (ACA) may have made insurance coverage more inclusive, but it keeps the insurance companies in charge of calling the shots (for those without Medicare, Veterans Care or Medicaid) and adding to the cost of health care through administrative costs and profit.

According to the advocacy organization Public Citizen, a number of experts from single-payer nations recently testified at a Senate sub-committee hearing chaired by Sen. Bernie Sanders (I-VT), a leading supporter of Medicare for all. The spokespersons from Canada and Denmark offered compelling reasons why the US should move from a private-insurance system to a government administered program (such as, well, Medicare):

For example, the Canadian witness, Dr. Danielle Martin, vice president of medical affairs and health system solutions at Women’s College Hospital, compared access to care, quality of care and costs in the U.S. and Canadian systems, and found all were superior in Canada. Martin compared the American average for administrative costs of 31 percent to the 1.3 percent administrative costs paid by Canada (not counting costs for private supplemental plans available to Canadians.) Professor Jakob Kjellberg from the Danish Institute for Local and Regional Government Research, who served as the Danish expert witness, said his country’s administrative costs are only 4.3 percent of total health care spending. 

In short, as has been argued before, private health insurance (which we still obviously have under the ACA) increases the cost of medical care, with nearly a third of that cost eaten up by private insurance non-health related revenue.  To repeat the testimony cited above: 31 percent of US health insurance costs goes to insurers, while in Canada only 1.3 percent of medical costs are administrative.

As far as access to care, to the contrary of what Sarah Palin infamously asserted — that government care would lead to death panels — it is private insurance companies who employ staff to decide whether medical care — sometimes a matter of life or death with chronic illnesses and rare diseases — should be provided.  Medicare does not employ “profit-increasers” to deny care.

Indeed, a spokesperson for Public Citizen pointedly summarized the hearing:

Today’s panel was a good first step that will hopefully inspire a real discussion about the benefits of single-payer health care in the United States, said Susan Harley, deputy director of Public Citizen’s Congress Watch division. A single-payer, or Medicare-for-all, system would eliminate health insurance companies from the equation, ensuring that only patients and their doctors make decisions about care options.

Although the ACA is to be praised for providing many uninsured people an opportunity to sleep with some peace of mind, it is still a rickety system constructed to ensure the political support of medical insurance companies.

US politicians, including President Obama, regularly boast about the US being the leader of the world in progress and a model for other nations.

Having the most expensive healthcare system, with the worst general outcome ranking for developed nations, looks like the US is a wobbly caboose not a powerful engine.

Medicare for all could solve that problem when it comes to cost-effectively fostering a healthy national population.

Afternote: The Daily Show, as usual, brought home the reality of the dysfunctional national US health care system in this recent segment. Click here.

Mark Karlin is editor of Buzzflash at Truthout.

http://www.truth-out.org/buzzflash/commentary/international-experts-tell-senators-that-single-payer-improves-national-health-at-less-cost

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What the U.S. can learn about health care from other countries

PNHP note: The following press release was issued by the staff of Sen. Bernie Sanders of Vermont on March 11.

Other major countries offer better health care at less cost than the United States, according to witnesses who testified on Tuesday at a Senate hearing chaired by Sen. Bernie Sanders. “What this hearing is really about is two fundamental issues. First, the U.S., the wealthiest country on the planet, is the only major industrialized country in the world that does not guarantee health care as a right to its citizens. Should we consider joining the rest of the world? I’d argue we should,” Sanders said. “Second, the U.S. spends twice as much as other countries that have much better health outcomes. What can we learn from these countries?” asked Sanders, chairman of the Senate Subcommittee on Primary Health and Aging.

Citing World Health Organization data, Sanders said the U.S. spends as much as three times more on health care than other industrialized countries. Health care outlays in the U.S. account for about 18 percent of our Gross Domestic Product, significantly more than in France, Germany, Denmark, Canada, Great Britain, Australia, Norway, Taiwan and Israel.

In Denmark, “all citizens have access to care; no one may be denied services on the basis of income, age, health or employment status,” according to Jakob Kjellberg, an economist from Copenhagen. Victor Rodwin, an expert on the French health care system, said “the French have easy access to primary health care, as well as specialty services, at half the per capita costs of what we spend in the U.S.

Other witnesses said the money Americans sink into their expensive health care system does not buy better care. “Canada achieved health outcomes that are at least equal to those in the U.S. at two-thirds the cost,” according to one witness at the hearing, Dr. Danielle Martin of Women’s College Hospital in Toronto.

The United States ranks 26th in life expectancy compared to other countries ranked by the Paris-based Organization for Economic Cooperation and Development. People who live in Italy, Spain, France, Australia, Israel, Norway and other countries live 2 to 3 years longer than Americans.

The Affordable Care Act has improved access to insurance, but millions of Americans still lack insurance or have plans with such high deductibles and copayments that they cannot afford the care they need. As a result, some 45,000 uninsured Americans die each year because they didn’t go to a doctor in time.

A major factor driving up health care costs in the U.S. is the high cost of prescription drugs. Hospital stays also cost more. While hospitals in Germany and France charge $3,000 for an appendectomy, for example, the average price for the same procedure in American hospitals is $13,000. Some U.S. hospitals charge $28,000.

“It is time for the U.S. to join the rest of the industrialized world and guarantee access to health care as a right of all people, not just a privilege for those who can afford it,” Sanders said.

http://www.sanders.senate.gov/newsroom/recent-business/us-can-learn-other-countries-health-care

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Testimony by international experts underscores benefits of single-payer health care systems

At congressional hearing, experts provide further evidence the U.S. should implement ‘Medicare for All’

By Public Citizen National Journal, March 11, 2014

WASHINGTON — Testimony given today by experts from Canada, Denmark, Taiwan and other countries underscores that single-payer health care systems remove the kind of hindrances to quality care that still plague the U.S., Public Citizen said today.

The witnesses provided compelling evidence to the members of the U.S. Senate Health, Education, Labor, and Pensions (HELP) Committee’s Subcommittee on Primary Health and Aging regarding the benefits of efficient, single-payer health care systems in their respective nations.

Citing cost savings and improved access to health care, expert witnesses explained to subcommittee members what’s been clear to Public Citizen for years: A Medicare-for-all, single-payer system would remove one of the main hurdles the U.S. faces in the quest to provide quality health care for everyone: high overall administrative charges from insurance companies.

For example, the Canadian witness, Dr. Danielle Martin, vice president of medical affairs and health system solutions at Women’s College Hospital, compared access to care, quality of care and costs in the U.S. and Canadian systems, and found all were superior in Canada. Martin compared the American average for administrative costs of 31 percent to the 1.3 percent administrative costs paid by Canada (not counting costs for private supplemental plans available to Canadians.) Professor Jakob Kjellberg from the Danish Institute for Local and Regional Government Research, who served as the Danish expert witness, said his country’s administrative costs are only 4.3 percent of total health care spending.

U.S. Sen. Bernie Sanders (I-Vt.), who chairs the subcommittee, is a longtime champion of single-payer health systems and introduced legislation late in 2013, the American Health Security Act of 2013 (S. 1782), to move the United States to a unified system of health care delivery. In addition, U.S. Rep. John Conyers (D-Mich.) has introduced single-payer legislation, the Expanded and Improved Medicare-For-All Act (H.R. 676).

Several witnesses discussed their countries’ goals of equity and how universal access to care was well-regarded by citizens. Dr. Ching-chuan Yeh of Taiwan, former health minister of Taiwan and professor at the School of Public Health, College of Medicine at Tzu Chi University, explained how the nation has achieved 99.6 percent coverage for the population and subsequently has seen increases in life expectancy and a drop in the infant mortality rate.

“Today’s panel was a good first step that will hopefully inspire a real discussion about the benefits of single-payer health care in the United States,” said Susan Harley, deputy director of Public Citizen’s Congress Watch division. “A single-payer, or Medicare-for-all, system would eliminate health insurance companies from the equation, ensuring that only patients and their doctors make decisions about care options.”

In addition to the national movement to adopt a single-payer health care system, state-based proposals have been put forward in several states (Vermont, New York, California, Pennsylvania, Minnesota, Hawaii and Colorado) that would require a single government payer for health care services instead of a patchwork of private and public health insurers. As explained by the subcommittee witnesses, such systems have a record of providing comprehensive, universal care at a significantly lower cost than we pay for the U.S.’s fragmented system, which leaves millions of people with no coverage.

“Public Citizen supports states moving toward single-payer systems and has outlined a road map for states to achieve the important goal of maximum coverage with minimum cost,” Harley said. “However, we need a national system that truly provides health care for all. We are encouraged by today’s hearing and look forward to a robust discussion about replicating the best of international models of single-payer here in the U.S.

http://www.nationaljournal.com/library/123291

By Elisabeth Rosenthal
The New York Times, March 8, 2014

Like most people, I am generally vigilant about paying my bills — credit cards, mortgage, cellphone and so on. But medical bills have a different trajectory. I (usually) open the envelopes and peruse the amalgam of codes and charges. I sigh or swear. And set them aside for when I have time to clarify the confusion: An out-of-network charge from a doctor I know is in-network? An un-itemized laboratory bill from a doctor I’ve never heard of? A bill for a huge charge before my insurer has paid its yet unknown portion of a hospital’s unknowable fee?

I would never countenance the phrase “60 days past due” on my Visa card statement. But medical bills? Well… with the complex negotiations that determine my ultimate payment, it often takes months to understand what I actually owe.

Unfortunately, I may be playing a dangerous game. Mounting evidence shows that chaos in medical billing is not just affecting our health care but dinging the financial reputation of many Americans: While the bills themselves frequently take months to sort out, medical debts can be reported rapidly to credit agencies, and often without notification. And even small unpaid bills can severely damage credit ratings.

A mortgage initiator in Texas, Rodney Anderson of Supreme Lending, recently looked at the credit records of 5,000 applicants and found that 40 percent had medical debt in collection, with the average around $400; even worse, most applicants were unaware of their debt. Richard Cordray, director of the federal Consumer Financial Protection Bureau, has noted that half of all accounts reported by collection agencies now come from medical bills, and the credit record of one in five Americans is affected.

A single medical bill reported to a credit agency can easily become a “millstone around your neck” said Mark Rukavina, principal at Community Health Advisors, a health care advisory service. He added: “It will take a long time to make that right, even once the bill is paid. I’ve had mortgage brokers call me and say ‘I have these people with great credit. They’ve refinanced before, but now they’ve got this medical bill and even though they’ve paid it off, I can’t get them a good rate.’ ”

Part of the problem is that there are few standards governing medical debts: One billing office might give you — or your insurer — 60 days to pay before pursuing collection. Another might allow you to pay off a bill slowly over a year. Many will sell the debt to collection companies, which typically take a cut of the proceeds and decide when or whether to report unpaid debt to credit agencies.

The problem is accelerating for several reasons. Charges are rising. Insurance policies are requiring more patient outlays in the form of higher deductibles and co-payments. More important, perhaps, is that while doctors’ practices traditionally worked out deals for patients who had trouble paying, today many doctors work for large professionally managed groups and hospital systems whose bills are generated far away, by computer.

Both Congress and the protection bureau have been trying to better insulate patient credit scores from the inefficiencies of our market-based medical system. Various proposals have been considered to differentiate medical debt from other forms; it could be erased once it has been paid off or not reported to credit agencies at all, for example. So far, the credit industry has fought successfully against such efforts, noting that they could allow some genuine scofflaws to evade legitimate charges. But it’s also good business, since health care bills are now the largest source of business for collection companies, according to consumer protection agency officials.

Having spent the last year reporting a series on American health costs, I’ve heard plenty about credit casualties.

Gene Cavallo, 61, a New Mexico businessman who put his children through college, had always paid his bills promptly and had an excellent credit rating, until he required surgical excision of a melanoma on his shin two years ago. The more than 60 bills generated for the surgery and six months of follow-up visits — arriving sporadically and ranging from 18 cents to $17,000 — came to $110,000; his insurance covered about $70,000.

When various providers asked him to pay the remaining $40,000, he requested itemized bills and balked at some of the “ridiculously inflated prices,” such as $85 for tweezers and $20 for a box of tissues. He argued the bills point by point, and ultimately agreed to pay $25,000.

But during the negotiations some of the debt was sent to collection. Two years later, he no longer answers the daily robocalls from collection agencies and has had a couple of credit cards canceled because his score has fallen. “It was a scary thing to do because I own a business and dabble in real estate, so the ability to borrow has always been important to me. And now I have no ability, I assume, to borrow for any reason.”

Michael S., who declined to give his full name so as to protect his reputation with business clients, had to declare bankruptcy in Wisconsin more than five years ago after a fraught year in which his toddler was evaluated for what proved to be a benign neurological condition that required no treatment: “You’d get bills for several different doctors’ groups and for tests and M.R.I.s and you don’t know what they are. I was having trouble figuring out who we owed what. And then, if it goes to collection, then suddenly they’re saying we need this paid now.”

With medical expenses, unlike most other purchases, you generally don’t know the price the hospital will charge in advance. And the subsequent bills and insurance statements — so-called explanations of benefits — are often layered in obfuscation and pressure tactics.

Consider Chris Sullivan of Pennsylvania, whose $2,770 bill for an echocardiogram offered a “prompt payment” discount of 20 percent if he wrote a check within 21 days — meaning a discount for not asking questions on a bill for a test he was told would be under $300.

Another “explanation of benefits” statement notified Joe Cotugno of New York City that his two-day hospital stay for a hip replacement was billed at $99,469.70 (doctors’ fees not included). Cigna paid $68,420.53 after knocking off some $28,000 and requiring Mr. Cotugno to pay $3,018.41. So, it informed him, “You saved 96 percent.” Huh?

The Consumer Financial Protection Bureau has been studying the impact of medical billing on credit scores since 2012, acknowledging that unpaid medical bills in collection “frequently end up on consumer credit reports,” as an outgrowth of “very complex and confusing systems of figuring out who owes what after a medical procedure.” Mr. Cordray, the bureau’s director, said it would take appropriate action if harmful practices were identified.

Bills in Congress that would regulate the practices have been stalled for years. The Medical Debt Relief Act was passed by the House in 2010, but never made it to a Senate vote. After a modified version of the bill failed to pass again last year, another act was recently introduced in the Senate and House.

Meanwhile, patients are right to worry. When Matt Meyer, who owns a saddle-fitting company in New Hampshire, set up a monthly payment plan after some surgery, he was distressed to notice that the invoices came from a debt collector. “I had no idea this was considered debt,” he said, and wondered: “Are they reporting that” to a credit agency?

Good question.

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.”