PNHP

Conyers Derides White House Strategy on Health Care

pnhpf3a

Conyers Derides White House Strategy on Health Care

By KATHARINE Q. SEELYE
Prescriptions Blog
New York Times
November 19, 2009

Representative John Conyers Jr., Democrat of Michigan and the second-most senior member of the House, today ripped into President Obama and Rahm Emanuel, the White House chief of staff, accusing them of “bowing down” to “nutty right-wing” proposals just to get a health care bill passed.

“I’m getting tired of saving Obama’s can in the White House,” Mr. Conyers, one of the most liberal members of the House and chairman of the Judiciary Committee, said in a radio interview on “The Bill Press Show.”

“I mean, he only won by five votes in the House, and this bill wasn’t anything to write home about,” Mr. Conyers said of the health care legislation that the House passed on Nov. 7. “The public option is only available — which is the only way you manage cost and give some competition to 1,300 other health insurance companies — the only way he could have got that through is that progressives held their nose and voted for the plan anyway.”

Mr. Conyers also complained that the idea of a single-payer system had been “taken off the table from the beginning.”

Asked if the president had shown enough leadership on health care, Mr. Conyers said, “Of course not, of course not.”

“You know,” he added, “holding hands out, and beer on Friday nights in the White House, and bowing down to every nutty right-wing proposal about health care, and saying on occasion that public options aren’t all that important, is doing a disservice to the Barack Obama that I first met, who was an ardent single-payer enthusiast himself.”

In the interview, Mr. Press said Democrats were saying that they feared the president would “just sign anything.”

Mr. Conyers agreed, saying “that’s essentially what Rahm Emanuel has said,” adding that he was tired of his approach of “give us anything and we will declare victory.”

“But look,” Mr. Conyers concluded, “the bill doesn’t go into effect for three years. Many of the people that we are trying to help will be dead by then.”

When the interview was over, Mr. Press said to his audience, “He’s in rare form this morning.”

http://prescriptions.blogs.nytimes.com/2009/11/19/conyers-derides-white-house-health-care-strategy/

If Mass. Small Businesses Want a Better Health Care Deal, They Should Back Single-Payer Health Care

By Jason Pramas
OMB Editorial
Open Media Boston
Nov. 15, 2009

It was strange to read today’s Boston Globe article about the response of some Massachusetts small businesses to the premium increases that the health insurance companies are proposing for next year. Though the average increase for small businesses will be 10 percent – an already ridiculously high figure – some of these businesses will see their premiums go up by much more than that. Especially clients of Blue Cross/Blue Shield – some of whom will see their premiums go up by nearly 50 percent. To progressives, it is hardly shocking news that health insurance companies are much like cats. In that the answer to the eternal question “why do cats lick themselves?” is more than passingly similar to the answer to the question “why do health insurance raise their premiums every year?” … because they can. At the moment, the MA Division of Insurance does not appear inclined to use its regulatory powers against health insurers that are gouging the public at every turn. So although Gov. Deval Patrick has asked the Division of Insurance to hold informational hearings on the small business premium increases, they probably won’t amount to much of anything in the way of reform. My concern here is not for small business owners, although I’m not unsympathetic to small businesses. I’m far more concerned about their employees – many of whom do not get health care benefits as it is. Except through the Mass. Health Connector system that forces all but the poorest individuals to buy iffy health care plans from the very same health insurers that are allowed to continue reaping huge profits even as the ranks of the jobless skyrocket. For those employees of small businesses that do get health care benefits through their employer, they will often be pushed from semi-decent private health care plans to worse plans in the Connector system.

This begs the question, “why do small businesses in Massachusetts continue to refuse to back single-payer health care at the national level?” Physicians for a National Health Program and other advocates have long pointed out that with an employer tax contribution of 7 percent of wages together with an employee contribution of 2 percent of wages that the federal government could run a program that would cover every single U.S. resident from cradle-to-grave – and provide top-flight medical, dental and vision coverage to all. For small businesses that provide health care benefits, such a plan would generally cost less than what they currently pay out to health insurers. For small businesses that don’t provide health care benefits, it would allow them to cover their employees for much less than existing plans cost. And for their employees, annual out-of-pocket costs would be much more reasonable then they are now.

Instead of supporting this logical solution to their health care cost woes, the small businesses quoted in the Globe piece mostly point fingers at the always rising fees charged to insurers by hospitals and doctors. Typically, they ignore the fact that health costs are going up for reasons that have much more to do with the existence of a private health care market then anything else. For example, with a national public health care system there would be no need for huge advertising budgets for hospitals, doctors groups, or insurers. Extra layers of bureaucracy currently needed for health care providers just to deal with health insurers can be eliminated. Chronic conditions will be better treated by front-line medical providers – reducing the need for people to rely on expensive critical care after years of having to neglect their health to save money. There would be less need for redundant expensive diagnostic equipment to be purchased by every hospital and clinic. Most importantly, doctors, hospitals and drug companies would be forced to negotiate reasonable rates with the national health care system – which would probably go very far towards keeping costs down.

So given all that, it makes even less sense that small business owners don’t start agitating along with other constituencies to demand a real universal national health plan rather than watch their health costs continue to go up until they cut the relatively meager benefits some of their workers currently enjoy.

I think it would behoove small business organizations to think hard about this issue. Because, even as I write, a really bad national plan that leaves giant insurance companies firmly in the drivers seat of American health are policy has been pushed through the House of Representatives and is on its way to the Senate for a vote – where it very well may get shot down. If it gets passed, it’s bad, because then all Americans will be forced to participate in a larger version of the Massachusetts experiment in a fake “universal” health care plan that seems to be just a way to force more people into buying inadequate private insurance. If it doesn’t get passed, that’s probably the better outcome. Although not really, because Americans will still lack a national health care system, and it will be another long wait before political momentum for reform builds up again. The entry of the small business sector into the debate on the side of single-payer health care – which is not even on the table nationwide – could be a real game-changer. Such a move would benefit working people in a big way. But it would also benefit the small business owners. Which would be an acceptable outcome from the perspective of this publication.

[Then we’d want to get small businesses to agree to stronger labor legislation. Though that fight would likely have to wait for another day.]

Jason Pramas is Editor/Publisher of Open Media Boston

Kaiser Issue Brief: Access to Abortion Coverage and Health Reform

Kaiser Family Foundation
Wednesday, November 18, 2009

A new issue brief from the Kaiser Family Foundation examines health reform and access to coverage for abortion services, a subject that has become one of the most discussed elements of the reform debate. The paper explains current law regarding abortion coverage, discusses the treatment of coverage for abortion services under the major health reform bills under consideration in Congress, and explores the possible impact of the House-passed legislation on public and private coverage for abortion services.

Under the House bill, 94% of the 12.4 million uninsured women of reproductive age have incomes that would likely qualify them for federal assistance in obtaining health coverage through Medicaid or the new health insurance exchange, and thus would likely be affected by the abortion coverage provisions. The brief breaks down these estimates state-by state, and also provides background on abortion in the U.S. and coverage of abortion services under current law and practice.

http://www.kff.org/healthreform/8021.cfm

Leading economists' advice to President Obama on controlling costs

Letter to President Barack Obama urging four elements be included in health reform legislation to control costs

By Alan M. Garber, Victor R. Fuchs, Kenneth J, Arrow

November 17, 2009

President Barack Obama
The White House
Washington, DC 20500
 
Dear Mr. President,

As the full Senate prepares to debate comprehensive health reform legislation, we write as economists to stress the potential benefits of health reform for our nation’s fiscal health, and the importance of those features of the bill that can help keep health care costs under control. Four elements of the legislation are critical: (1) deficit neutrality, (2) an excise tax on high-cost insurance plans, (3) an independent Medicare commission, and (4) delivery system reforms.

Including these four elements in the reform legislation – as the Senate Finance Committee bill does and as we hope the bill brought to the Senate floor will do – will reduce long-term deficits, improve the quality of care, and put the nation on a firm fiscal footing. It will help transform the health care system from delivering too much care, to a system that consistently delivers higher-quality, high-value care. The projected increases in federal budget deficits, along with concerns about the value of the health care that Americans receive, make it particularly important to enact fiscally responsible and quality-improving health reform now.

In developing our analysis and recommendation, we received input and suggestions from Administration officials, including the Office of Management and Budget and others, as well as from economists who disagree with the Administration’s views.

The four key measures are:

* Deficit neutrality

Fiscally responsible health reform requires budget neutrality or deficit reduction over the coming years. The Congressional Budget Office (CBO) must project that the bill be at least deficit neutral over the 10-year budget window, and deficit reducing thereafter. Covering tens of millions of currently uninsured people will increase spending, but the draft health reform legislation contains offsetting savings sufficient to cover those costs and the seeds of further reforms that will lower the growth of spending. Deficit neutrality over the first decade means that, even during the start-up period, the legislation will not add to our deficits. After the first decade, the legislation should reduce deficits.

* Excise tax on high-cost insurance plans

The Senate Finance Committee’s bill includes an excise tax on high-cost health insurance plans. Like any tax, the excise tax will raise federal revenues, but it has additional advantages for the health care system that are essential. The excise tax will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount. In addition, as employers and health plans redesign their benefits to reduce health care premiums, cash wages will increase. Analysis of the Senate Finance Committee’s proposal suggests that the excise tax on high-cost insurance plans would increase workers’ take-home pay by more than $300 billion over the next decade. This provision offers the most promising approach to reducing private-sector health care costs while also giving a much needed raise to the tens of millions of Americans who receive insurance through their employers.

* Medicare Commission

Rising Medicare expenditures pose one of the most difficult fiscal challenges facing the federal government. Medicare is technically complex and the benefits it underwrites are of critical importance to tens of millions of seniors and Americans with disabilities. We believe that a commission of medical experts should be empowered to suggest changes in Medicare to improve the quality and value of services. In particular, such a commission should be charged with developing and suggesting to Congress plans to extend the solvency of the Medicare program and improve the quality of care delivered to Medicare beneficiaries. Creating such a commission will make sure that reforming the health care system does not end with this legislation, but continues in future decades, with new efforts to improve quality and contain costs.

* Delivery system reforms

Successful reform should improve the care that individual patients receive by rewarding health care professionals for providing better care, not just more care. Studies have shown that hundreds of billions of dollars are spent on care that does nothing to improve health outcomes. This is largely a consequence of the distorted incentives associated with paying for volume rather than quality. Health care reform must take steps to change the way providers care for patients, to reward care that is better coordinated and meets the needs of each patient. In particular, the legislation should include additional funding for research into what tests and treatments work and which ones do not. It must also provide incentives for physicians and hospitals to focus on quality, such as bundled payments and accountable care organizations, as well as penalties for unnecessary re-admissions and health-facility acquired infections. Aggressive pilot projects should be rapidly introduced and evaluated, with the best strategies adopted quickly throughout the health care system.

As economists, we believe that it is important to enact health reform, and it is essential that health reform include these four features that will lower health care costs and help reduce deficits over the long term. Reform legislation that embodies these four elements can go a long way toward delivering better health care, and better value, to Americans.

Sincerely,

Dr. Henry Aaron, The Brookings Institution
Dr. Kenneth Arrow, Stanford University, Nobel Laureate in Economics
Dr. Alan Auerbach, University of California, Berkeley
Dr. Katherine Baicker, Harvard University
Dr. Alan Blinder, Princeton University
Dr. David Cutler, Harvard University
Dr. Angus Deaton, Princeton University
Dr. J. Bradford DeLong, University of California, Berkeley
Dr. Peter Diamond, Massachusetts Institute of Technology
Dr. Victor Fuchs, Stanford University
Dr. Alan Garber, Stanford University
Dr. Jonathan Gruber, Massachusetts Institute of Technology
Dr. Mark McClellan, The Brookings Institution
Dr. Daniel McFadden, University of California, Berkeley, Nobel Laureate in Economics
Dr. David Meltzer, University of Chicago
Dr. Joseph Newhouse, Harvard University
Dr. Uwe Reinhardt, Princeton University
Dr. Robert Reischauer, The Urban Institute
Dr. Alice Rivlin, The Brookings Institution
Dr. Meredith Rosenthal, Harvard University
Dr. John Shoven, Stanford University
Dr. Jonathan Skinner, Dartmouth College
Dr. Laura D’Andrea Tyson, University of California, Berkeley

Letter:
http://iis-db.stanford.edu/pubs/22739/Economist_Letter_to_the_President.pdf

The source of the letter:
http://healthpolicy.stanford.edu/publications/letter_to_president_barack_obama_urging_four_elements_be_included_in_health_reform_legislation_to_control_costs/

OECD Tax Database (Table 0.1):
http://www.oecd.org/document/60/0,2340,en_2649_34533_1942460_1_1_1_1,00.html

Bundled payments and ACOs:
https://pnhp.org/news/2009/november/rand-and-br-on-savings-through-bundled-payments

Comme
nt:

By Don McCanne, MD

For socially conscious health care reform advocates, the primary goal of reform is to see that every individual receives the health care that he or she needs, But what has really driven the reform process has been the concern over the very high costs of health care that have challenged individuals, employers and the stewards of our government health programs.

In this late phase of the reform process many have expressed doubts over the adequacy of the various policies in the reform proposal that allegedly are designed to control health care costs well into the future. In response, twenty-three of the nation’s most distinguished economists have signed on to this letter addressed to President Obama expressing support for four elements that they believe are of critical importance and should be included in the reform legislation. Let’s look closer at these four elements.

* Deficit neutrality

The economists call for budget neutrality initially, to be followed by deficit reduction. Of course they are referring only to the federal government budget and not to private sector spending. The great risk of limiting consideration to public spending is that, in the absence of effectively controlling actual health care costs, the government budget can be controlled only by shifting the costs to the private sector. Individuals and businesses certainly do not want to see an increase in their health care spending, especially while the government is reducing its spending in the later phase, that of deficit reduction.

Isolating health care spending for budget neutrality while continuing with deficits in other government programs (war, financial institution bailouts, interest on the debt, expanding our prison population, etc.) does not seem just. Appropriate use of debt is fundamental to any business, and there is no reason that reasonable debt should not be a part of the government’s management of its financial obligations to health care.

That said, our total government debt is the result of prior devious efforts to reduce revenues (i.e., taxes) in order to force the reduction in funding of government programs. With inadequate revenues and with exploding debt, deficit hawks in Congress can be relied upon to underfund crucial programs such as health care, but theirs is a pathological process since they only look at spending and refuse to consider revenues.

Those who argue that taxes collected for government health care spending remove money from the economy are flat out wrong. Health care is one of the most important and beneficial components of our economy, constituting over 17 percent of our GDP (Gross Domestic Product). Those taxes are moved back into our economy.

Those who scream that we are being taxed to death need another dose of reality. The average total tax revenues of OECD nations (Organization for Economic Cooperation and Development) was 35.9 percent of GDP in 2006. For the United States, the total tax revenue was 28.0 percent of GDP, placing us near the bottom of OECD nations. (OECD Tax Database – link above)

Suppose we increased our tax revenues to the average of OECD nations, which would still be far, far short of those nations with more highly socialized systems. At 7.9 percent (35.9 average minus 28.0 U.S.) of our GDP of about $13.8 trillion, that would increase government revenues by about $1.1 trillion in a single year, ten times the amount they are considering for health care reform. Our entire federal spending is under $3 trillion. We could eliminate entirely the deficits and provide surpluses while keeping tax revenues at well below the OECD average, if only the deficit hawks would look at the revenue side of the ledger.

* Excise tax on high-cost insurance plans

Why would any health insurance plans have very high premiums? One reason is that insurers use medical underwriting to assess high premiums for individuals with preexisting disorders. It would be unfair to tax those premiums for an individual with other burdens, but with adequate regulatory reform medical underwriting should be eliminated anyway.

The more common reason for high premiums is that the plan covers other services and products such as dental care, eye care, maternity benefits, mental health services, and pharmaceuticals. Applying an excise tax to these premiums would result in eliminating such benefits from the plans and shifting these expenses to the individual in the form of greater out-of-pocket spending. The proposals under consideration place a cap on out-of-pocket expenses for covered services, but that cap is unaffordable for many, and these expenses would not apply to the cap. Thus they would impose an even greater financial burden.

Since the excise tax would discourage access to these important health care services, it should be rejected as the flawed policy concept that it is.

* Medicare Commission

Although the Medicare Commission purportedly would be to improve quality and value, its primary purpose would be to limit spending within the Medicare program. Medicare has already served as a leader in innovations to reduce health care spending, with the private insurance industry following. In fact, many providers believe that Medicare has been too aggressive, often resulting in lower reimbursement rates than in the private sector. Granting the Commission more power to use newer innovations to further reduce spending will inevitably increase the animosity held towards Medicare by the providers. A decline in willingness to accept Medicare beneficiaries could further impair access.

This is not to say that the concept of a commission is a bad idea. If the commission worked with the entire health care delivery system in applying potentially beneficial innovations, higher quality and greater value are possible. If the commission became too aggressive, the push-back by providers and their patients would moderate their excesses.

If the power of the Medicare Commission were limited only to Medicare, then there is a potential that cost-cutting aggressiveness might threaten to convert Medicare into a quasi-welfare program not unlike Medicaid, a transformation that would not please our Medicare beneficiaries. It is more likely that the Commission simply would be enmeshed in studies of relatively ineffectual measures that would have little net impact on costs.

We would need a universal Medicare for all program for the Commission to have a real impact that would be both beneficial and cost saving.

* Delivery system reforms

These economists recommend that we reward health professionals for providing better care. The problem is that we don’t know how to do that. They recommend funding research into what tests and treatments work and which ones do not, as if that isn’t what research has been all about anyway. Maybe it would be helpful to directly compare expensive patent drugs to generics, but the overall spending impact will be modest since this year’s patented drugs are next year’s generics.

They also recommend bundled payments, accountable care organizations, plus penalties for re-admissions, hospital acquired infections and other PACs (potentially avoidable costs). In my message two days ago I already discussed the reasons why these measures cannot be relied upon to reduce health care costs (Bundled payments and ACOs – link above).

Is this really the best that these noted economists can come up with? They have made the same mistake as the politicians. Their perception of reform is to build on our existing dysfunctional financing system (an egregiously flawed concept that you would think our leading economists would understand).

If we had an improved Medicare for all we could have 1) deficit neutrality through global budgeting, 2) rational tax policies that are equitable, 3) public administration using the guidance of commissions as appropriate, and 4) our own beneficent monopsony t
hat can realign incentives to promote the delivery system reform that we need. And, oh yes, every single person would be included. It doesn’t take an economist to understand that.

Leading economists’ advice to President Obama on controlling costs

Letter to President Barack Obama urging four elements be included in health reform legislation to control costs

By Alan M. Garber, Victor R. Fuchs, Kenneth J, Arrow

November 17, 2009

President Barack Obama
The White House
Washington, DC 20500
 
Dear Mr. President,

As the full Senate prepares to debate comprehensive health reform legislation, we write as economists to stress the potential benefits of health reform for our nation’s fiscal health, and the importance of those features of the bill that can help keep health care costs under control. Four elements of the legislation are critical: (1) deficit neutrality, (2) an excise tax on high-cost insurance plans, (3) an independent Medicare commission, and (4) delivery system reforms.

Including these four elements in the reform legislation – as the Senate Finance Committee bill does and as we hope the bill brought to the Senate floor will do – will reduce long-term deficits, improve the quality of care, and put the nation on a firm fiscal footing. It will help transform the health care system from delivering too much care, to a system that consistently delivers higher-quality, high-value care. The projected increases in federal budget deficits, along with concerns about the value of the health care that Americans receive, make it particularly important to enact fiscally responsible and quality-improving health reform now.

In developing our analysis and recommendation, we received input and suggestions from Administration officials, including the Office of Management and Budget and others, as well as from economists who disagree with the Administration’s views.

The four key measures are:

* Deficit neutrality

Fiscally responsible health reform requires budget neutrality or deficit reduction over the coming years. The Congressional Budget Office (CBO) must project that the bill be at least deficit neutral over the 10-year budget window, and deficit reducing thereafter. Covering tens of millions of currently uninsured people will increase spending, but the draft health reform legislation contains offsetting savings sufficient to cover those costs and the seeds of further reforms that will lower the growth of spending. Deficit neutrality over the first decade means that, even during the start-up period, the legislation will not add to our deficits. After the first decade, the legislation should reduce deficits.

* Excise tax on high-cost insurance plans

The Senate Finance Committee’s bill includes an excise tax on high-cost health insurance plans. Like any tax, the excise tax will raise federal revenues, but it has additional advantages for the health care system that are essential. The excise tax will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount. In addition, as employers and health plans redesign their benefits to reduce health care premiums, cash wages will increase. Analysis of the Senate Finance Committee’s proposal suggests that the excise tax on high-cost insurance plans would increase workers’ take-home pay by more than $300 billion over the next decade. This provision offers the most promising approach to reducing private-sector health care costs while also giving a much needed raise to the tens of millions of Americans who receive insurance through their employers.

* Medicare Commission

Rising Medicare expenditures pose one of the most difficult fiscal challenges facing the federal government. Medicare is technically complex and the benefits it underwrites are of critical importance to tens of millions of seniors and Americans with disabilities. We believe that a commission of medical experts should be empowered to suggest changes in Medicare to improve the quality and value of services. In particular, such a commission should be charged with developing and suggesting to Congress plans to extend the solvency of the Medicare program and improve the quality of care delivered to Medicare beneficiaries. Creating such a commission will make sure that reforming the health care system does not end with this legislation, but continues in future decades, with new efforts to improve quality and contain costs.

* Delivery system reforms

Successful reform should improve the care that individual patients receive by rewarding health care professionals for providing better care, not just more care. Studies have shown that hundreds of billions of dollars are spent on care that does nothing to improve health outcomes. This is largely a consequence of the distorted incentives associated with paying for volume rather than quality. Health care reform must take steps to change the way providers care for patients, to reward care that is better coordinated and meets the needs of each patient. In particular, the legislation should include additional funding for research into what tests and treatments work and which ones do not. It must also provide incentives for physicians and hospitals to focus on quality, such as bundled payments and accountable care organizations, as well as penalties for unnecessary re-admissions and health-facility acquired infections. Aggressive pilot projects should be rapidly introduced and evaluated, with the best strategies adopted quickly throughout the health care system.

As economists, we believe that it is important to enact health reform, and it is essential that health reform include these four features that will lower health care costs and help reduce deficits over the long term. Reform legislation that embodies these four elements can go a long way toward delivering better health care, and better value, to Americans.

Sincerely,

Dr. Henry Aaron, The Brookings Institution
Dr. Kenneth Arrow, Stanford University, Nobel Laureate in Economics
Dr. Alan Auerbach, University of California, Berkeley
Dr. Katherine Baicker, Harvard University
Dr. Alan Blinder, Princeton University
Dr. David Cutler, Harvard University
Dr. Angus Deaton, Princeton University
Dr. J. Bradford DeLong, University of California, Berkeley
Dr. Peter Diamond, Massachusetts Institute of Technology
Dr. Victor Fuchs, Stanford University
Dr. Alan Garber, Stanford University
Dr. Jonathan Gruber, Massachusetts Institute of Technology
Dr. Mark McClellan, The Brookings Institution
Dr. Daniel McFadden, University of California, Berkeley, Nobel Laureate in Economics
Dr. David Meltzer, University of Chicago
Dr. Joseph Newhouse, Harvard University
Dr. Uwe Reinhardt, Princeton University
Dr. Robert Reischauer, The Urban Institute
Dr. Alice Rivlin, The Brookings Institution
Dr. Meredith Rosenthal, Harvard University
Dr. John Shoven, Stanford University
Dr. Jonathan Skinner, Dartmouth College
Dr. Laura D’Andrea Tyson, University of California, Berkeley

Letter:
http://iis-db.stanford.edu/pubs/22739/Economist_Letter_to_the_President.pdf

The source of the letter:
http://healthpolicy.stanford.edu/publications/letter_to_president_barack_obama_urging_four_elements_be_included_in_health_reform_legislation_to_control_costs/

OECD Tax Database (Table 0.1):
http://www.oecd.org/document/60/0,2340,en_2649_34533_1942460_1_1_1_1,00.html

Bundled payments and ACOs:
https://www.pnhp.org/news/2009/november/rand-and-br-on-savings-through-bundled-payments

Comment:

By Don McCanne, MD

For socially conscious health care reform advocates, the primary goal of reform is to see that every individual receives the health care that he or she needs, But what has really driven the reform process has been the concern over the very high costs of health care that have challenged individuals, employers and the stewards of our government health programs.

In this late phase of the reform process many have expressed doubts over the adequacy of the various policies in the reform proposal that allegedly are designed to control health care costs well into the future. In response, twenty-three of the nation’s most distinguished economists have signed on to this letter addressed to President Obama expressing support for four elements that they believe are of critical importance and should be included in the reform legislation. Let’s look closer at these four elements.

* Deficit neutrality

The economists call for budget neutrality initially, to be followed by deficit reduction. Of course they are referring only to the federal government budget and not to private sector spending. The great risk of limiting consideration to public spending is that, in the absence of effectively controlling actual health care costs, the government budget can be controlled only by shifting the costs to the private sector. Individuals and businesses certainly do not want to see an increase in their health care spending, especially while the government is reducing its spending in the later phase, that of deficit reduction.

Isolating health care spending for budget neutrality while continuing with deficits in other government programs (war, financial institution bailouts, interest on the debt, expanding our prison population, etc.) does not seem just. Appropriate use of debt is fundamental to any business, and there is no reason that reasonable debt should not be a part of the government’s management of its financial obligations to health care.

That said, our total government debt is the result of prior devious efforts to reduce revenues (i.e., taxes) in order to force the reduction in funding of government programs. With inadequate revenues and with exploding debt, deficit hawks in Congress can be relied upon to underfund crucial programs such as health care, but theirs is a pathological process since they only look at spending and refuse to consider revenues.

Those who argue that taxes collected for government health care spending remove money from the economy are flat out wrong. Health care is one of the most important and beneficial components of our economy, constituting over 17 percent of our GDP (Gross Domestic Product). Those taxes are moved back into our economy.

Those who scream that we are being taxed to death need another dose of reality. The average total tax revenues of OECD nations (Organization for Economic Cooperation and Development) was 35.9 percent of GDP in 2006. For the United States, the total tax revenue was 28.0 percent of GDP, placing us near the bottom of OECD nations. (OECD Tax Database – link above)

Suppose we increased our tax revenues to the average of OECD nations, which would still be far, far short of those nations with more highly socialized systems. At 7.9 percent (35.9 average minus 28.0 U.S.) of our GDP of about $13.8 trillion, that would increase government revenues by about $1.1 trillion in a single year, ten times the amount they are considering for health care reform. Our entire federal spending is under $3 trillion. We could eliminate entirely the deficits and provide surpluses while keeping tax revenues at well below the OECD average, if only the deficit hawks would look at the revenue side of the ledger.

* Excise tax on high-cost insurance plans

Why would any health insurance plans have very high premiums? One reason is that insurers use medical underwriting to assess high premiums for individuals with preexisting disorders. It would be unfair to tax those premiums for an individual with other burdens, but with adequate regulatory reform medical underwriting should be eliminated anyway.

The more common reason for high premiums is that the plan covers other services and products such as dental care, eye care, maternity benefits, mental health services, and pharmaceuticals. Applying an excise tax to these premiums would result in eliminating such benefits from the plans and shifting these expenses to the individual in the form of greater out-of-pocket spending. The proposals under consideration place a cap on out-of-pocket expenses for covered services, but that cap is unaffordable for many, and these expenses would not apply to the cap. Thus they would impose an even greater financial burden.

Since the excise tax would discourage access to these important health care services, it should be rejected as the flawed policy concept that it is.

* Medicare Commission

Although the Medicare Commission purportedly would be to improve quality and value, its primary purpose would be to limit spending within the Medicare program. Medicare has already served as a leader in innovations to reduce health care spending, with the private insurance industry following. In fact, many providers believe that Medicare has been too aggressive, often resulting in lower reimbursement rates than in the private sector. Granting the Commission more power to use newer innovations to further reduce spending will inevitably increase the animosity held towards Medicare by the providers. A decline in willingness to accept Medicare beneficiaries could further impair access.

This is not to say that the concept of a commission is a bad idea. If the commission worked with the entire health care delivery system in applying potentially beneficial innovations, higher quality and greater value are possible. If the commission became too aggressive, the push-back by providers and their patients would moderate their excesses.

If the power of the Medicare Commission were limited only to Medicare, then there is a potential that cost-cutting aggressiveness might threaten to convert Medicare into a quasi-welfare program not unlike Medicaid, a transformation that would not please our Medicare beneficiaries. It is more likely that the Commission simply would be enmeshed in studies of relatively ineffectual measures that would have little net impact on costs.

We would need a universal Medicare for all program for the Commission to have a real impact that would be both beneficial and cost saving.

* Delivery system reforms

These economists recommend that we reward health professionals for providing better care. The problem is that we don’t know how to do that. They recommend funding research into what tests and treatments work and which ones do not, as if that isn’t what research has been all about anyway. Maybe it would be helpful to directly compare expensive patent drugs to generics, but the overall spending impact will be modest since this year’s patented drugs are next year’s generics.

They also recommend bundled payments, accountable care organizations, plus penalties for re-admissions, hospital acquired infections and other PACs (potentially avoidable costs). In my message two days ago I already discussed the reasons why these measures cannot be relied upon to reduce health care costs (Bundled payments and ACOs – link above).

Is this really the best that these noted economists can come up with? They have made the same mistake as the politicians. Their perception of reform is to build on our existing dysfunctional financing system (an egregiously flawed concept that you would think our leading economists would understand).

If we had an improved Medicare for all we could have 1) deficit neutrality through global budgeting, 2) rational tax policies that are equitable, 3) public administration using the guidance of commissions as appropriate, and 4) our own beneficent monopsony that can realign incentives to promote the delivery system reform that we need. And, oh yes, every single person would be included. It doesn’t take an economist to understand that.

Massachusetts physicians say reform in their state is no model for the nation

Nearly 200 sign ad urging single-payer health care reform

FOR IMMEDIATE RELEASE      
Nov. 17, 2009

Contact:
Rachel Nardin, M.D.
Steffie Woolhandler, M.D., M.P.H.
Mark Almberg, Physicians for a National Health Program, (312) 782-6006, mark@pnhp.org

In a half-page advertisement appearing in Wednesday’s (tomorrow’s) Boston Globe, 196 Massachusetts physicians and physicians-in-training call the state’s 2006 health reform plan “bad medicine” and warn against adopting the state’s plan nationwide. The health bill recently passed by the U.S. House of Representatives is closely modeled after the Massachusetts reform.

According to the U.S. Census Bureau, the Massachusetts reform has left hundreds of thousands uninsured. The doctors’ ad, which takes the form of a letter to their patients, warns that the state’s plan is already failing. Health costs have escalated rapidly since the reform’s implementation. According to the Boston Globe, the state’s largest insurer will hit small businesses with average premium increases of 15 percent to 18 percent as of January 1.

As an alternative to Massachusetts-style reform, the letter proposes a single-payer health care plan – Medicare for All. Such reform would cover everyone and control costs through massive savings on bureaucracy as well as improved health planning.

“Physician voices have been conspicuously absent from the national debate on health care reform,” said Dr. Rachel Nardin, a neurologist at Harvard Medical School and one of the letter’s lead signers. “This letter is a chance to let our patients know that the current plans for reform will fail to control costs or to give American families real access to the health care they need.”

Another lead signer of the letter, Dr. Steffie Woolhandler, a primary care doctor who is a professor of medicine at Harvard, noted, “This reform has left many of my patients worse off than before. Co-payments and deductibles are sky high and premiums are unaffordable. A middle-class woman who’s 56 is forced to lay out at least $4,800 for a policy so skimpy that it pays nothing until she has paid another $2,000 in deductibles. Meanwhile, the state has drained funds from safety net hospitals and clinics to fund the reform, threatening the survival of the institutions that care for the hundreds of thousands who remain uninsured.”

*******

A PDF of the ad with its 196 signers can be found here:
https://pnhp.org/docs/2009/Mass-Ad-Boston-Globe.pdf

The full text of the original letter can be found here: www.pnhp.org/ma

For detailed price quotes on insurance available under the Massachusetts reform, see http://tinyurl.com/nv9vqb

*******

Physicians for a National Health Program (www.pnhp.org) is an organization of 17,000 doctors who advocate for single-payer national health insurance. To contact a physician-spokesperson near you, visit www.pnhp.org/stateactions or call (312) 782-6006.

Uninsured trauma patients

Downwardly Mobile - The Accidental Cost of Being Uninsured

By Heather Rosen, MD, MPH; Fady Saleh, MD, MPH; Stuart Lipsitz, ScD; Selwyn O. Rogers Jr, MD, MPH; Atul A. Gawande, MD, MPH
Archives of Surgery
November 2009

The Centers for Disease Control and Prevention estimate that in 2004, there were 112 012 deaths related to unintentional injuries alone in the United States. Unintentional injury is within the top 10 causes of death for every age group and is the leading cause of death among persons aged 1 to 44 years.

Uninsured trauma patients in the NTDB (National Trauma Data Bank) had a statistically significant higher adjusted odds of mortality compared with insured trauma patients. Our subgroup analyses strongly corroborated these findings. In younger patients (aged 18-30 years), the adjusted odds of mortality after trauma remained higher for uninsured patients compared with insured patients, indicating that the differences persist in a relatively healthy cohort. In the subgroup analyses of head-injured patients and those with 1 or more comorbidities in the NTDB, the adjusted odds of mortality in the uninsured population remained significantly high.

Most recent research has concentrated on decreased (or lack of) access to care as a result of being uninsured. However, we found that, even after admission to a hospital, trauma patients can have worse outcomes based on insurance status. This concerning finding warrants more rigorous investigation to determine why such variation in mortality would exist in a system where equivalent care is not only expected but mandated by law.

We can only speculate as to the mechanism of the disparities we have exposed; the true causes are still unclear. Although the lack of insurance may not be the only explanation for the disparity in trauma mortality, the accidental costs of being uninsured in the United States today may be too high to continue to overlook.

http://archsurg.ama-assn.org/cgi/content/short/144/11/1006

Comment:

By Don McCanne, MD

Uninsured trauma patients are more likely to die than insured patients in spite of the fact that treatment is mandated by law. This study did not explain the reasons for the differences.

Delay? Different care? Lower health literacy? Or was there simply less enthusiasm on the part of the providers of care once it was realized that they would not be compensated for their efforts?

This study and several others have demonstrated that death can be a consequence of being uninsured. But there are other important consequences as well. Access to health care that can maintain or improve quality of life is impaired, with consequent adverse outcomes. Financial hardship is almost a given in uninsured individuals with significant health problems.

Instead of searching for alternative explanations for adverse outcomes in the uninsured, we should admit that being uninsured is bad for your health and bad for your finances, and then do something about it. Individual responsibility alone is not enough. Social solutions are required.

Study: Injured uninsured more likely to die in ER

By CARLA K. JOHNSON (AP)
November 16, 2009

CHICAGO — Uninsured patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance, according to a troubling new study.

The findings by Harvard University researchers surprised doctors and health experts who have believed emergency room care was equitable.

“This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States,” said senior author Dr. Atul Gawande, a Harvard surgeon and medical journalist.

The study, appearing in the November issue of Archives of Surgery, comes as Congress is debating the expansion of health insurance coverage to millions more Americans. It could add fodder to that debate.

The researchers couldn’t pin down the reasons behind the differences they found. The uninsured might experience more delays being transferred from hospital to hospital. Or they might get different care. Or they could have more trouble communicating with doctors.

The hospitals that treat them also could have fewer resources.

“Those hospitals tend to be financially strapped, not have the same level of staffing, not have the same level of surgeons and testing and equipment,” Gawande said. “That also is likely a major contributor.”

Gawande favors health care reform and has frequently written about the inequities of the current system.

The researchers took into account the severity of the injuries and the patients’ race, gender and age. After those adjustments, they still found the uninsured were 80 percent more likely to die than those with insurance — even low-income patients insured by the government’s Medicaid program.

“I’m really surprised,” said Dr. Eric Lavonas of the American College of Emergency Physicians and a doctor at Denver Health Medical Center. “It’s well known that people without health insurance don’t get the same quality of health care in this country, but I would have thought that this group of patients would be the least vulnerable.”

Some private hospitals are more likely to transfer an uninsured patient than an insured patient, said Lavonas, who wasn’t involved in the new research.

“Sometimes we get patients transferred and we suspect they’re being transferred because of payment issues,” he said. “The transferring physician says, ‘We’re not able to handle this.'”

Federal law requires hospital ERs to treat all patients who are medically unstable. But hospitals can transfer patients, or send them away, once they’re stabilized. A transfer could worsen a patient’s condition by delaying treatment.

The researchers analyzed data on nearly 690,000 U.S. patients from 2002 through 2006. Burn patients were not included, nor were people who were treated and released, or dead on arrival.

In the study, the overall death rate was 4.7 percent, so most emergency room patients survived their injuries. The commercially insured patients had a death rate of 3.3 percent. The uninsured patients’ death rate was 5.7 percent. Those rates were before the adjustments for other risk factors.

The findings are based on an analysis of data from the National Trauma Data Bank, which includes more than 900 U.S. hospitals.

“We have to take the findings very seriously,” said lead author Dr. Heather Rosen, a surgery resident at Los Angeles County Hospital, who found similar results when she analyzed children’s trauma data for an earlier study. “This affects every person, of every age, of every race.”

Solidarity, Individualism and Public Goods

Obama's Flawed Case Against Single Payer

By ALAN NASSER
Counterpunch
November 16, 2009

The liberal imagination has broadened the scope of what it wants to dismiss as unrealistic, utopian and unpragmatic, i.e. as for all practical purposes impossible. These claims have typically been accompanied by the assurance that “This is not something that Americans would go for – it’s not the American way.”  There are countless variations on this theme. Obama’s case against a single payer health care system  is a conspicuous case in point. What distinguishes Obama’s position on this issue is not merely the weakness of his “arguments”, but the straight-ahead factual falsehood of the some of the counterclaims he has put forward in order to turn the desirable into the impossible.

The Alleged Impossibility of Universal Health Care

In May and August, 2007 Obama stated his position on single payer:

“If you’re starting from scratch, then a single-payer system’-a government-managed system like Canada’s, which disconnects health insurance from employment-‘would probably make sense. But we’ve got all these legacy systems in place, and managing the transition, as well as adjusting the culture to a different system, would be difficult to pull off. So we may need a system that’s not so disruptive that people feel like suddenly what they’ve known for most of their lives is thrown by the wayside.” (May, 2007)

” [W]hen we had a healthcare forum before I set up my healthcare plan here in Iowa there was a lot of resistance to a single-payer system. So what I believe is we should set up a series of choices….Over time it may be that we end up transitioning to such a system. For now, I just want to make sure every American is covered…I don’t want to wait for that perfect system…” (August, 2007, at an Iowa roundtable)

Obama offers 5 reasons for not supporting single payer.

First: “..we’ve got all these legacy systems in place” simply means that our system is not single payer, and we’ve had it for a long time. Obama has turned himself into a bent sort of Burkean conservative: we have been marinating in a tradition which so permeates our way of being in the world that to do away with it would upset social life as we know it. This tradition includes…. insurance-industry-based health care! More mundanely: we haven’t got it, so we can’t have it.

Second: it would be hard to “manage the transition” from a deeply flawed system to a much better one. Harder than it was to effect the transition to Social Security, Medicare, Medicaid, desegregation, etc.? In each of these cases, what many people had “known for most of their lives” [was] “thrown by the wayside”. It belongs to the nature of any move from one way of doing things to a very different one that the transition will take some doing. That fact alone settles nothing. What matters is how urgent is the need for change. The US’s irrationally costly system which leaves millions uninsured, a fate suffered by the citizens of no other developed capitalist country, is surely intolerable. We have been given no reason to think that the cost of a transition to universal coverage is so great as to outweigh the massive benefits of  this tried and tested arrangement. Obama’s excuses amount to a cleverly disguised a-priori argument against any consequential transformation of the status quo.

Third: the “difficulty” [i.e. costs] of  “adjusting the culture to a different system”, given that there is “a lot of resistance to a single-payer system” , outweigh the benefits of single-payer. But what matters is not what a few selected Iowans are alleged to have felt about universal coverage. The demonstrated preferences of the democratic majority can’t be irrelevant. 

On this issue Obama clearly means to imply that “Americans” don’t support single-payer. This is factually false. It’s improbable that Obama is unaware of the results of many surveys on this issue, the most recent, to my knowledge, having been conducted between December 14-20, 2007. The results of this Associated Press-Yahoo poll are worth reproducing as they were reported:

Subjects were asked which of the following 2 views comes closest to their own view:

1. The United States should continue the current health insurance system in which most people get their health insurance from private insurers, but some people have no insurance.

2. The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.

A majority of 65% supported 2, 34% supported 1 and 2% did not respond.

Those polled were also asked “Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?”

55% answered Yes, 44% No and 2% did not respond. Single-payer still has a majority here, but a smaller one, probably due to the pollsters’ use of (what is to some) the red-flag term ‘single payer’. [View the full poll results at http://news.yahoo.com/]

Taxpayer funded, government-run health care insurance for all is a public, not a private, good, and it is the only political project that most Americans are on record as willing to pay higher taxes to achieve. There is in fact not “a lot of resistance” to a rational health care system. Obama knows this. But the interests of those who have heavily invested (literally) in him carry more weight than do the most pressing interests of the rest. 

The Ideology of Individual Choice and the Logic of Solidarity

Fourth: Obama claims that a health care plan based on “a series of choices” is superior to one that leaves no choice but instead saddles everyone with the burden of full and affordable coverage. Pity those poor Europeans, deprived of their right to liberty by forced access to first-rate health care. In the City on the Hill, few things are more important than the right to choose: which health care system gives us the most choice? This way of thinking is saturated with the ideology of individualism and its private goods, and functions to obliterate solidarity, as opposed to self-interest, as a political and moral value. This is especially pernicious since, as we shall see, it is only concerted action motivated by solidarity that can bring about a health care system from which no one is excluded because they can’t afford it.

When Obama contradistinguishes choice from universal coverage he unwittingly underscores the irrelevance of individual, self-interested choice to political goals motivated by a commitment to solidarity. Preoccupation with the choice between one doctor and another, one plan or another, conceals a crucial assumption, namely that the fundamental issue underlying the health care debate is one about choice and liberty. An individualist ontology implies that our collective fate is a function of whether or not each individual member of society is savvy enough to make the free choices most likely to promote his or her self-interest. But are people who worry about access to health care really concerned with choice? What weighs upon them is that they can’t afford health care. No individual can make on her own the choice to turn the US into a country that makes health care affordable, available to all. Such a choice is not a choice by an individual about her own well being. It is not even a choice about the aggregate sum of each and every individual’s well being. It is a choice we make together about the kind of society we want to live in. To worry about health care because one cannot affor
d it is, on reflection, to lament the non-existence of a  public good, universally accessible health care, one that can’t be reduced to the sum of all individual goods. The survey discussed above indicates that most Americans implicitly know this. The majority endorse a universally applicable measure, taxation, as a means to institute a universally available, i.e. public, good, access to health care. A universal tax, as for education, roadways, health care, is not an individual cost; it is a social cost. Correspondingly, universally accessible health care is not an individual good, it is a public good. The majority would prefer to live in the kind of society that features that public good. It’s a different kind of society from the one we’re currently stuck with.

That kind of society, and the public goods it prioritizes, can be achieved only if it is pursued as a goal by people acting in concert. That’s where solidarity is on display: in collective action motivated by the desire to achieve a public good.

The kinds of goals/goods in question typically involve bringing about a certain kind of society. For example: the kind of society that provides all with affordable health care, the kind of society that makes access to the means of life  -e.g. a living wage-  available to all, the kind of society that makes the meeting of human needs the principal motivator of economic production, the kind of society that assigns sufficient resources to the reduction of pollution and the preservation of nature,… Prattling on about individual choice creates a conceptual space within which considerations of solidarity and public goods cannot arise. Talking about solidarity in the language of individualism is like trying to score a field goal in baseball.

Obama references affordability in spite of himself when he  claims (falsely) that he wants to “make sure that every American is covered”. The fundamental virtue of single payer is that it detaches insurance from employment and thereby from one’s level of income, so that everyone can afford health care. The question of choice doesn’t even arise if you can’t afford to keep yourself healthy. And come to think of it, were health care universally available, the question of affordability would not arise. Talk of being able to “afford” access to health care would be as misplaced as talk of being able to afford access to elementary education.

Solidarity As a Familiar Phenomenon

The issue is worth dwelling on. In everyday life we are all familiar with the pursuit of irreducibly social goods. Think of a family with kids. A rare and highly desirable work opportunity, but far from home, arises for spouse #1. Spouse #2 has come upon a comparable golden opportunity, also far from home. The family wants to stay together. A decision based on the good of either individual spouse would break up the family. What to do? It’s not uncommon in such a situation for the adults to look to determine what would be good for the family. And what’s good for the family is not the sum of spouse #1’s good plus spouse #2’s good, plus the goods of each individual child.  We cannot commensurate and then sum up these different and sometimes incompatible goods. The good of the family is irreducibly social, just like universally accessible health care. Families and households act in solidarity all the time.

Obama’s repeated insistence on the market as the primary agent in distributing resources precludes consideration of questions of solidarity from the outset. He is the instrument of domestic advisors benighted by preposterous economic theories hailing the efficiency and liberty-promoting virtues of the market. For these wags the pursuit of individual self-interest, plus competition, makes the world go round and secures for us all the freedom we (are allowed to) want. As we have seen above, the restriction of human-welfare-enhancing political choices to the realm of competition and self-interest deprives us of the freedom collectively to choose to live in the kind of society that provides copious public goods. That’s a big freedom lost.

The Political Psychology of Solidarity

A sense of solidarity is far more prevalent in much of Europe than it is in the Land of the Free. In a New York Times article titled “For the French, Solidarity Still Counts”  (by Youseff M. Ibrahim, Dec. 20, 1995), the author describes public reaction in France to a three-week strike by public workers supported by “hundreds of thousands of demonstrators who filled the streets of every major city in France.” Workers were protesting then Prime Minister Juppe’s proposal to slash medical, social welfare and benefit payments. According to the Times:

“Polls showed an astonishing amount of sympathy on the part of those who did not participate in the strike and who suffered the paralysis of mass transit and essential services. Many people explained that they supported the strike because the Government’s austerity programs are stripping layer after layer of subsidies that permitted French families of even the most modest means to sample the cultural and culinary treasures that only the rich can afford.”

One recipient of the social wage was a woman receiving the standard subsidy extended to pregnant women. The subsidy will continue, for each child, until the child reaches 18. Said the woman: “This is the foundation of our Republican system… Equality and fraternity are not mere slogans here. For me the engagement by the state is an expression of solidarity that gives us values… I think most French people want France’s values to be decided by this spirit, not by cold, remote, economic summits that speak of deficits and competition. That was the message of the strikes.”

This past March one million demonstrated across France in protest of proposed cutbacks in the wake of the financial crisis. I am currently living in France for a stretch of time and have witnessed frequent strikes and other expressions of resistance to neoliberal austerity measures. A sad and stark contrast to the sitting-duck posture of so many US workers.

The Times article provides an implicit explanation of why it is that in France and other European countries there is no general resentment of social benefits available, for example, to single mothers, while in the US more than a few working people oppose this kind of support. The Times reports that the subsidy offered to the woman quoted above “is extended to every mother in France regardless of economic or marital status.” In France benefits to single mothers are not regarded as “special treatment” denied to the responsible and hard-working. There is neither social nor psychological soil in which to plant the seeds of resentment, since the single mother is the recipient of a public good available to all mothers.

Fifth and finally: “I just want to make sure every American is covered…I don’t want to wait for that perfect system…” If the president truly wanted to guarantee universal coverage he would not have taken single-payer off the table before discussions began. Whatever is finally settled upon, government will neither negotiate drug prices nor regulate premiums, so we know now that millions will remain uninsured. Obama has known that all along.

Obama rigs the game by characterizing single-payer as “that perfect system”. One of the major weapons in the party-liners’ arsenal is to portray those who believe in greater possibilities as naïve utopians blind to the truism that a “perfect world” is impossible in what William F. Buckley liked to call “this veil of tears”. The logic is fine: since there are no finite limits to the greater possibilities of goodness, and perfection is conceived, as Anselm reminds us, as that greater than which none can be conceived, it follows that perfection is impossile down here. But whoever introduced mumbo-jumbo about perfection in the first place? Isn’t the elimination of a
great deal of unnecessary suffering enough? Last I recall, single-payer advocates claim merely (sic) that it is way better than what we are offered. That’s pretty good.

Obama’s case against single-payer frames health-care priorities in the language of atomic individualism. Hence, the range of possible outcomes is determined for the worse before discussion begins. I am suggesting that a good part of our resistance and organizing should consist in reminders that an alternative way of thinking and acting is already on display in some of our common practices, and in already existing benefits won for other populations by aiming at public goods to be achieved by concerted action in solidarity.

Hope that helps.

Alan Nasser is professor emeritus of Political Economy and Philosophy at The Evergreen State College in Olympia, Washington. He can be reached at nassera@evergreen.edu

http://www.counterpunch.org/nasser11162009.html

Clarifying what single-payer health care is and is not

By Howard Waitzkin
Taos News
Thursday, 18 July 2009

First I congratulate Justin Bailey, Erich Kuerschner, and all other people in the Taos area who are working hard to reform our health care system.

Although I support these efforts, I want to clarify what single-payer health care is and is not. In their articles, both Bailey and Kuerschner argued on behalf of a single-payer system but did not address several of its key features.

A single-payer health program basically would extend Medicare to the entire population. Although Medicare is not without problems, people over 65 years of age widely support the system and express satisfaction with it.

Under Medicare, the government occupies a very small role. The government collects payments from workers and employers and then distributes funds to health care providers for the services that Medicare patients receive.

Because it is such a simple system, the administrative costs under Medicare average between 3 and 5 percent, according to most studies. This small percentage means that the vast majority of Medicare expenditures pay for clinical services as opposed to administrative expenses.

On the other hand, private insurance generally shows administrative expenses between 20 and 30 percent. This much larger percentage means that about one quarter of every dollar spent on health care goes for administrative costs.

Many of these expenditures pay for activities such as billing, denial of claims, supervision of co-payments and deductibles, scrutiny of pre-existing conditions that disqualify people from care, and exorbitant salaries for executives (in many cases totaling between $10 and 20 million per year).

A single-payer national health program would achieve universal access to care by drastically reducing administrative waste. Because private insurance companies no longer could spend money keeping people out of the system, all of us would receive the care that we need without co-payments, deductibles, or other expenses at the point of service.

Under a single-payer system, the average family and the average business would spend the same or less than they currently spend on medical expenses.

Unfortunately, the Obama Administration and many of our Congressional representatives do not support the single-payer proposal, even though national polls consistently show that the majority of people in our country favor this approach.

The Obama administration has proposed a “mixed approach,” which includes a “public option,” organized along the lines of a single-payer system. However, the overall national health program would include the current private insurance industry and would therefore maintain a much higher level of administrative costs than a single payer approach.

Because the mixed approach will achieve much less savings by reducing administrative waste, the projected costs of the system have become prohibitive. Concern about these high costs has become the focus of the current debate in Congress.

On the other hand, there are two important bills in Congress that would achieve a single-payer system. In the House of Representatives, the bill is HR676, introduced by Rep. John Conyers and cosponsored currently by 85 other representatives. Sen. Bernard Sanders recently introduced a similar bill, S703, in the Senate.

These bills deserve our support because they truly would achieve a single-payer national health program that would guarantee universal access for all of us.

It is wonderful to realize that our own Rep. Ben Ray Lujan became a cosponsor of HR676 shortly after he entered Congress in early 2009.
Carlos Cisneros and Roberto (Bobby) Gonzales have introduced similar single payer legislation in the New Mexico Legislature.

Although Sen. Tom Udall did cosponsor single-payer legislation in previous sessions of Congress, he has not yet cosponsored 5703 since he entered the Senate this year.

Sen. Jeff Bingaman has not cosponsored S703, even though he generally supports improved access to health care.

President Obama consistently has argued that it is important to preserve the for-profit private insurance industry as part of his proposal – with even more tax subsidies for the industry. The Obama proposal essentially will compel families and individuals to buy insurance, from either the private industry or the government, with the poor assisted through a means-testing approach with huge administrative costs.

The mixed private and public approach has failed to achieve universal coverage in multiple states (most recently Massachusetts) and countries.

Let’s focus our attention and organizing on the real single¬ payer approach, which is the only way to avoid the failure to achieve universal health care which has plagued us for so many years.

As Winston Churchill said, “Americans will always do the right thing – after they’ve tried every other option.”

Howard Waitzkin, M.D., a professor at the University of New Mexico-Albuquerque, lives and practices medicine in Taos. He helped write the single-payer proposal of Physicians for a National Health Program, a professional organization with about 20,000 members www.pnhp.org. This proposal led to the current legislative bills in Congress that would enact a single-payer national health program (HR676 and S703).