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Crush of cancer, medical bills snares family

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Crush of cancer, medical bills snares family

By Stephanie Smith
CNN Medical Producer
Tue October 13, 2009

WEST PALM BEACH, Florida (CNN) — Leslie Elder’s eyelids fluttered open, and through the fog of pain medication, she saw the emergency room doctors pull back the curtain in her room.

She could tell that the news was bad.

“They didn’t have to say a word. I knew from their faces that something wasn’t right,” said Elder, 60, who hours earlier had stumbled into the ER with a stabbing pain in her abdomen. “Then one doctor said, ‘Your right kidney … it’s breaking apart. You have a tumor … and you also have a tumor in your left kidney.’ ”

The words “You have a tumor” were not new to Elder; her grim financial situation was.

Elder had cancer twice before — in 1988, doctors found a tumor in her right breast, and in 2001, they found one in her left breast — except back then, she was insured. By the time she learned that she had kidney cancer in September 2005, she was uninsured.

“All I could think of was ‘Oh, my god, I’m going to go broke. We’ll be living in a cardboard house,’ ” Elder said. ” ‘How am I going to do this?’ It was the most honest feeling of powerlessness.”

Insurance conflict

Elder and her husband, Jim, say their health insurance carrier, Nationwide Insurance, forced them into an impossible situation by raising the rates on their policy over several years. Eventually, they were forced to cancel.

“Nationwide denies any inference that the company inappropriately raised rates for the coverage that was provided from 1987 until the time the Elders canceled the policy,” spokeswoman Liz Christopher said in a statement.

The Elders are broke and on the cusp of bankruptcy because of medical bills, and they’re not alone. A study published in the June issue of the American Journal of Medicine found that in 2007, 62 percent of personal bankruptcies were because of medical debts. The same study indicated that in 1981, only 8 percent of bankruptcy filings could be traced to medical bills.

“Health insurance premiums track directly with the underlying cost of medical care,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, which represents 1,300 health insurance carriers in the United States. “As the cost of providing care increases, premiums increase accordingly.”

The Elders boil it down to health insurance companies putting profits ahead of human life. VideoWatch more on the Elders’ struggle »

“The insurance companies are choosing who will live and who will die,” Leslie Elder said.

Nationwide Insurance says it did not break any law by increasing the Elders’ insurance premium.

“Health insurance rates were and are highly regulated by various state insurance departments, and any premium increases for the Elders and other policyholders would have been made in full compliance with state laws in effect at that time,” Christopher said.

The Florida Department of Insurance Regulation, which oversees companies like Nationwide, said in a statement, “There is no law that limits the amount of rate requested by an insurer.” Insurance officials add that their office reviews all rate requests, ensuring that the requests are not excessive or discriminatory.

The Elders bristle at the notion that their experience could be cast as anything but “excessive” and “discriminatory.”

Health care bills before the Senate and House are designed, in part, to rid the market of health care discrimination, especially as it relates to pre-existing conditions like Elder’s cancer.

Zirkelbach says the industry agrees with removing pre-existing conditions from consideration for pricing policies but stresses that reform should not come by way of raising taxes or cutting benefits for other programs like Medicare.

The Obama administration has said repeatedly that health care reform would not cut benefits or raise taxes.

The Elders are not hopeful that health care reform — even if it excludes pre-existing condition clauses from health insurance policies — will help them any time soon.

According to the bill currently before the House, it will be 2014 before self-employed families like them will actually have access to health insurance. By then, Elder will be near eligibility for Medicare.

While the debate in Congress continues, Elder says she is waiting anxiously — waiting for reform, and for her cancer to come back.

A contentious relationship

The Elders did not always have such a contentious relationship with their health insurance carrier, and they were not always broke. In fact, before their insurance troubles, they were solidly middle-class business owners.

However, in 1988, things began changing. It was the year of Elder’s first breast cancer diagnosis. When the family’s plan required payment of a $250 deductible and a 20 percent share of the costs of medical care, the Elders could afford it.

Years after that first diagnosis, things started getting shaky. Jim Elder says the premiums crept up slowly at first and then more dramatically.

“You do ask why, why, why,” Jim Elder said. “Why are we stuck with all these huge bills when we’re supposedly covered?”

A recent Kaiser Family Foundation study examining U.S. health insurance policies generally found that from 1999 to 2009, the average family premium more than doubled. The Elders say that over the life of their Nationwide Insurance policy, their premiums nearly quadrupled.

The Elders believe that their health insurance premiums soared higher than those of the average family because of Leslie’s previous cancer diagnosis.

“What is the message here? Survive cancer but then go drop dead because we can’t make any money off you anymore?” Leslie Elder asked. “[The insurance companies] figure, ‘You’re useless. Get lost.’ ”

Nationwide says, “While we’re empathetic to the Elders’ situation, we stand by the policy coverages provided to the Elders while they were customers.”

To cope with high premiums, the Elders played a precarious, yet common, game. They increased their deductible to offset the high premiums. By the time Leslie Elder got breast cancer for a second time, in 2001, the family’s deductible was up to $5,000.

What happened next would send shock waves through the Elder household.

“As I’m recuperating, I receive $21,000 of bills that I was responsible for,” Leslie Elder said. Under the Elders’ policy with Nationwide they did, in fact, owe so much, in part because of rising health care costs, and in part because their deductible was now so high.

She was stunned and confused — not just about the bills but about how they were going to pay. What still confounds Leslie and Jim Elder: How the cost of medical care, and medical insurance, went sky high in just over a decade.

Late in 2001, the Elders were scrambling for affordable coverage. They dropped their policy with Nationwide Insurance and signed up for a more affordable policy with Aetna, by starting a group policy including employees in a small business they were running at the time. Eventually, Aetna would increase the Elders’ premium to nearly $1,000 per month. It was too much. In 2005, the Elders dropped their health insurance policy for the second time.

“I sat down and seriously thought about it for a long time and said, ‘I’m not going to do this,’ ” Leslie Elder said. “I am not going to pay. Never mind ‘I’m not going to’; there was no way I could.”

In a statement, Aetna said that Leslie Elder’s previous cancer diagnoses were not the culprit for the rate increase.

Although the company did not cite a specific reason for the increased rate, Cynthia Michener, an Aetna spokeswoman said: “There can be other contributing factors to rate increases for small business policies, including, for example, the aggregate cost of the entire pool of small business policies in the state.”

Zirkelbach said, “Everybody who has health care coverage should have the peace of mind that their coverage is going to be there when they need it. We have proposed to eliminate pre-existing condition exclusions entirely so that everybody has peace of mind that coverage will be there, that they won’t be paying based on their health status.”

Through it all, there was one bright spot: A generous family member paid the more than $80,000 in hospital bills stacked up during Leslie Elder’s 2005 kidney cancer treatment. Still, the family is struggling to pay down the bill of more than $21,000 from 2001.

Leslie Elder says that even if she could afford it, because of her pre-existing condition, she is “uninsurable.” Without coverage, she cannot afford follow-up exams for cancer, so Elder has no idea whether her cancer has come back. In a strange way, she says, not knowing is better.

“I don’t think I could bear to listen to those words again. … ‘You have cancer,’ ” Elder said. “I’ve said to my husband, if I start to get sick, just set me up with a nice pill cocktail on a beach, because nobody cares. That’s the message you hear every day from insurance companies.”

What about primary care?

"Uncomplicated" Primary Care?

By Josh Freeman
Medicine and Social Justice
October 8, 2009

I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.

However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position.

Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from (their Physicians Foundation report) they note:

“Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care.”

The American Academy of Family Physicians (AAFP) in its formal response to the Physicians Foundation report includes the following:

“This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as ‘anomalous’ and ‘simple frameworks’ without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”

Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care”. What is this “uncomplicated primary care” of which you speak?

The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult.

(Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He is author and editor of the Medicine and Social Justice blog.)

http://medicinesocialjustice.blogspot.com/2009/10/uncomplicated-primary-care.html

And…

Health Bills In Congress Won’t Fix Doctor Shortage

By Phil Galewitz
Kaiser Health News
October 12, 2009

Even as Congress moves to expand health insurance coverage to millions of Americans, it’s doing little to ensure there will be enough primary care doctors to meet the expected surge in demand for treatment, experts say.

The American Academy of Family Physicians predicts that the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine.

A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions — a 15 percent increase that would favor more primary care training — was considered dead on arrival because of its $10 billion price tag over a decade.

Instead, the House and Senate overhaul bills would redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies.

Proposals to significantly increase Medicare payments for primary care doctors have gone nowhere in part because the money would come from payments to higher-paid specialists — who, not surprisingly, oppose a pay cut.

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said the extra training slots emanating from the redistribution of unfilled residency position would amount to a “drop in the bucket.”

http://www.kaiserhealthnews.org/Stories/2009/October/12/primary-care-doctor-shortage.aspx

Comment:

By Don McCanne, MD

The report by Dr. Cooper and his colleagues, cited by Dr. Freeman, was “A Report to the President and the Congress.” Since it was released only one month ago, this report likely did not influence the current legislation, but it is important because it does represent the cavalier views of all too many within and outside of the health care arena.

One of the promises of reform was to reinforce our primary care infrastructure. Although there are a few measures in the bill such as a nominal primary care bonus and a medical home pilot project, failure to train more primary care physicians will require many patients to rely on expensive care in our emergency rooms and expensive care through often inappropriate, direct self-referral to specialists.

We were promised that everyone would be covered and costs would be controlled. Neither will happen. And now the promise of providing primary care access to everyone will fall far short. Jiggling 1000 existing medical residencies just won’t do it.

Senate Finance bill is no solution to health care crisis

FOR IMMEDIATE RELEASE
Oct. 13, 2009

Contact:
Quentin Young, M.D., (312) 782-6006
Mark Almberg, (312) 782-6006, cell: (312) 622-0996

Dr. Quentin Young, national coordinator of Physicians for a National Health Program (www.pnhp.org), made the following statement today:

“The Senate Finance Committee bill, which passed this afternoon in committee, preserves all the systemic deficiencies that we see in our present health care financing model. It maintains a system that is based on private insurance and for-profit, private insurers. It therefore cannot and will not provide truly universal, comprehensive and affordable care.

“According to the Congressional Budget Office, the bill, even with its mandate requiring people to buy insurance, will leave 25 million people uninsured. An even greater number will be underinsured, i.e. vulnerable to financial ruin in the event of a serious illness.

“The Senate bill will be unable to contain costs, which are projected to double in the next decade.

“While it is possible to temporarily expand coverage by subsidizing the purchase of private coverage, as the Senate bill does, such an approach is not sustainable. It won’t cover everybody and it will fall apart quickly due to rising costs, as we’ve seen with similar approaches in Massachusetts, Vermont, Oregon, Tennessee and Minnesota.

“The insurance companies’ drive to fight claims, issue denials, screen out the sick and make a big profit generates tremendous administrative waste — $400 billion a year.

“In contrast, by replacing our dysfunctional, for-profit, multi-payer system with a streamlined, nonprofit social insurance program — single-payer Medicare for All — we can recapture the $400 billion that is presently wasted on bureaucracy and paperwork and use that money to provide comprehensive, high quality care for everyone. And we won’t have to spend a penny more than our nation does now.

“There’s no getting around the fact that single-payer Medicare for All remains the only realistic solution to our profound health care crisis. As big as the challenge may be, Congress should act accordingly.”

Physicans for a National Health Program is an organization of 17,000 doctors who support single-payer national health insurance. For more information, visit www.pnhp.org or call (312) 782-6006.

Harris offers wrong fix for health care

By Dr. Taro J. Adachi
Letters
The Baltimore Sun
Oct. 7, 2009

Dr. Andy Harris has made a misdiagnosis of the underlying problem in U.S. health care and his suggestions for treatment are off (“Reform, not overreach,” Oct. 6).

He’s shared a misconception that competition among insurers would bring down the cost of health care insurance. That was the original concept before the industry went to a for-profit model. Since that time, the annual cost of care for individuals and families has risen steadily.

The 2009 Kaiser Family Foundation’s annual survey of health benefits notes that despite these hard economic times and the focus on health insurance costs, the average annual premiums for employer sponsored health insurance are $4,824 for single coverage and $13,375 for family coverage — a 5 percent increase from last year alone. Workers contributions, annual deductibles and copays all went up.

These are the real costs that are affecting the economics of companies large and small. On the patient side of the economics, even families with supposedly good coverage are just one serious illness away from financial ruin. According to a Harvard study from this summer , illness and medical bills contribute to 62 percent of personal bankruptcies — a 50 percent increase since 2001. And three-quarters of the medically bankrupt had insurance, at least when they first got sick.

Coverage that families bought in good faith failed to protect them. Some were bankrupted by co-payments, deductibles and loopholes. Others got too sick to work, leaving them unemployed and uninsured. Now Congress plans to make it a federal offense not to purchase such faulty insurance.

Dr. Harris and I do agree with things we want in health care reform. We want coverage for all for medically necessary care at a lower cost. The real solution has become evident to most Americans. Most physicians and patients now want national health care. The single-payer bill HR 676 will come up for a promised vote on the floor of the House this month. This bill is publicly funded and your care is delivered by the physician or institution of your choosing. Everyone is covered — really. Politicians have called this impossible, but the Congressional Budget Office says it would save at least $350 billion a year, partly by cutting out the expensive, profit-taking health insurance companies. At the very least, your representatives in Congress need to hear your voice now. Let them be led by their constituents and not their campaign budgets funded by the very health insurance industry that they are supporting with other proposals.

The writer heads the Maryland Chapter of Physicians for a National Health Program.

http://www.baltimoresun.com/news/opinion/letters/bal-healthletter1007b,0,2619550.story

Seven Arrested at Chicago Cigna Health Insurance Office Calling for End to Denial of Treatment, Real Health Care Reform

Sit-in is part of a national mobilization to end insurance abuse and win health care for all

FOR IMMEDIATE RELEASE
October 8, 2009
4:48 PM

CONTACT: Mobilization for Health Care for All
Edward Crouse, (773) 301-7468, edsahotel@gmail.com
Lacy MacAuley, (202) 445-4692, lacy@massey-media.com
Follow us on Twitter @mob4healthcare

CHICAGO – October 8 – Seven citizens and health care providers who are fed up with the state of our health care and the health care debate were arrest at the downtown offices of Cigna today. The sit-in is part of a national mobilization to end insurance abuse and build support for real reform – Medicare for All, a single-payer plan. The mobilization involves civil disobedience at insurance company offices in New York, Chicago, Los Angeles, Washington DC, and other cities. Almost 700 people have already signed up to risk arrest at a health insurance company office, joining one of the largest campaigns of nonviolent civil disobedience since the civil rights movement. Many of these event are occurring next week on Thursday, October 15 in a dozen cities across the country.

The seven participants walked into the lobby and demanded to speak with the CEO of Cigna, demanding immediate approval of all doctor-recommended treatments. When access was refused, they sat down in the lobby of the building, Chanting “patients, not profits,” and “Cigna is the real death panel.” They put themselves on the line for people who die every day because an insurance company denies them the care that they need, and are calling for real reform, which eliminates the real cause of the health care crisis in our country, the insurance companies.

Participants in the rally outside the health insurance office included Mary E. Flowers, State Representative of the 31st district, and Midge Hough, a Chicago resident whose daughter-in-law Jenny died five weeks ago as a result of inadequate care. Jenny was seven and a half months pregnant and diagnosed with acute pneumonia. Carrying a sign with a picture of Jenny on it, Hough encourages others to stand up for quality health care for all.

“We lost Jennifer, and we lost our grandchild. She can’t speak up for herself anymore, but I’m going to speak for Jennifer,” said Hough while standing outside the Cigna office. “Tomorrow is her memorial service or I would have been one of the people sitting inside… This is the richest country in the world and my daughter in law and my grandchild died, and I can’t accept that.”

Participants in today’s sit-in are part of a national mobilization which will be one of the largest campaigns of nonviolent civil disobedience in the US since the civil rights movement. Next week, citizens and health care providers will participate in sit-ins in Atlanta, Seattle, Los Angeles, Philadelphia, Washington DC, Cleveland, Portland, and many other cities across the country. Most participants in these actions have signed up just in the past ten days, and are coming out of the woodwork to stand for an end to insurance abuse and win health care for all.

“Hundreds of people die each day because insurance companies deny them lifesaving care that they need,” said Marilena Marchetti, 29, an occupational therapist and a resident of Gold Coast, Chicago, who was arrested at today’s sit-in. “I put myself on the line for them. We need a system that places patients before profit.”

The sit-in is part of the Patients Not Profit campaign of the Mobilization for Health Care for All. The mobilization was launched by the organizations Prosperity Agenda, Healthcare-NOW!, and the Center for the Working Poor. The local group that organized today’s activities is the Chicago Single Payer Action Network (Chi-SPAN), a group of individuals committed to health care for all.

“At this critical juncture in the national health care debate, we are highlighting deaths and suffering caused by insurance company denials. In some states 20% of all doctor-approved health care recommendations are denied by insurance companies. People are dying because these corporations put profits before patients,” said Katie Robbins of Healthcare-NOW!

Experts agree that the current health care bill is not helping.

“The health care bill currently being debated in Congress is a giveaway to the insurance industry. Tens of millions of Americans will be forced to buy overpriced insurance, which will result in hundreds of billions in new annual revenue for the insurance industry,” said Kevin Zeese, executive director of Prosperity Agenda. “A Medicare for All system would cover all Americans, unlike the Dem proposal which will leave tens of millions without coverage, and would reduce the cost of health care immediately saving $400 billion annually in insurance company profits, executive salaries and bureaucracy.”

Rodberg – Is There Any Way Out for Obama?

Is There Any Way Out for Obama?

By Leonard Rodberg

Progressives worry that, if Obama’s health reform plan (hereafter called the “Plan”) fails to pass, a latter-day right-wing Gingrich movement will take over the Congress in 2010 and the White House in 2012. What I have not heard, but what I am increasingly coming to believe, is that, if the Plan passes in any of its current forms, things will go just as badly for him! Why is that?

The general reason is that the Plan is a DOG. It is a terrible, complex plan that will accomplish almost nothing. Relatively few people will benefit from it, while everyone who has to use health care will continue to experience the mess that is, and will continue to be, the American health care system. And, because of the new requirements built into the Plan, health care finance will become even more complex and confusing.

More specifically:

1. The large majority of people, who receive their insurance from their employer, will see no benefit whatsoever from the Plan. Most will, in fact, find their premiums rising as new requirements imposed by the Plan (e.g., the elimination of lifetime limits) raise the cost of insurance. And, of course, to their undoubted surprise, most of them will not have access to the public option, even if there is one.

2. Most provisions of the Plan will not become effective until 2013. This gives four years for Republicans to criticize the Plan, including (1) its use of cuts in Medicare reimbursements and Medicare Advantage premiums as principal sources of funding, (2) its lack of any real or believable mechanism for containing costs, and (3) its bureaucratic complexity.

3. The taxes on high-cost insurance plans, the other principal source of funding, will cause those who now have good insurance (called, pejoratively, “Cadillac” plans) to find these plans heavily taxed and their employers given a strong incentive to cut back on their benefits. Instead of reducing underinsurance, this part of the Plan will increase it! (And the rest of the plan does little about underinsurance at all.)

4. During the four years of waiting for the Plan to take effect, costs will continue to rise. By the time the Plan takes effect, costs are likely to be at least 25% greater than now. Even more people will find insurance and health care unaffordable. People will ask “What was health reform about?” The disillusionment will be great.

5. The complexity of the plan, including (1) federal rules regarding what kinds of employer-based insurance plans are “qualified,” (2) new income tax forms that will be needed to implement the individual mandate, and (3) the process of determining income eligibility for everyone, will all lend themselves to criticism and even ridicule.

Is there a way out? Not, in my view, as long as Obama sticks with this worthless and unworkable Plan. Only if we were to adopt a much simpler plan that would benefit everyone — a Medicare for All plan — would he be seen as actually addressing the problem and really offering a workable solution. Short of that, he, and all of us, are in real trouble.

(Leonard Rodberg, Ph.D. is Professor and Chair, Urban Studies Department, Queens College/CUNY.)

Comment:

By Don McCanne, MD

“If we don’t pass this…”

You hear that phrase in almost every speech made in support of the “Plan” – the reform proposal of President Obama and the Democrats in Congress. It has the implicit threat that if the Plan is not passed, we will be condemned to continue to live with the deteriorating health care mess that we now have. If we do pass the Plan, we will be condemned to live with the deteriorating health care mess that we will have – the mess that Professor Rodberg so adeptly describes.

With all of the rhetoric about choice, why should we be limited to these two options? Neither one is acceptable!

We cannot leave things the way they are. Yet we cannot allow this awful legislation to pass. We may have to have a lockdown of Congress until they get it right, but, if that’s what it takes, let’s do it!

A Death Every 12 Minutes: The Price of Not Having Medicare for All

By John Geyman
The Huffington Post
Posted: September 18, 2009

Americans are dying at a faster rate — 1 every 12 minutes, 5 an hour, 120 a day, 45,000 a year — not from war or natural disaster, but from lack of health insurance.

That’s the stunning finding of a study published today in the American Journal of Public Health by leading researchers at Harvard Medical School. The report, “Health Insurance and Mortality in U.S. Adults,” reveals that the uninsured have a 40 percent higher risk of death than those with private insurance, resulting in 45,000 preventable deaths annually.

These are our friends and neighbors, our fellow Americans who can’t afford or otherwise get private health insurance. Increasingly, this group includes nearly all lower-income and a growing majority of middle-class Americans.

The Institute of Medicine estimated in 2002 that more than 18,000 Americans between the ages of 19 and 64 were dying each year as a result of being uninsured. The new number is two and a half times that figure.

Trying to get by, the uninsured and underinsured delay necessary care, put off filling drug prescriptions or take only some of their medications each day. Most are just one major illness or accident away from financial ruin.

A growing number of patients with cancer have to turn down recommended chemotherapy or radiation treatment because of inability to pay for care. If they have insurance, many find that the small print in their policies excludes such coverage. If they are uninsured, their risk of death multiplies. No one in dire need of medical care should be put in this lose-lose situation.

We’re not talking about a third world country. This is the United States, one of the most industrialized nations in the world. But increasingly, we look more like a developing country — 42nd in the world for life expectancy (behind Japan and most of Europe), and ranked last among 19 OECD countries in preventable deaths that should not occur in the presence of timely and effective health care.

Meanwhile, the charade goes on, as our elected representatives in Congress dither over health care reform. None of the bills in Congress will resolve the affordability and access problems.

The Congressional Budget Office estimates the House health reform bill would still leave 17 million persons uninsured and that Sen. Baucus’ bill, unveiled yesterday, would leave 25 million uninsured. That translates into tens of thousands of unnecessary deaths every year.

There are now 3,300 health industry lobbyists running around Washington, D.C., trying to shape the small print to their advantage in whatever bill finally gets passed (if any). The insurance and pharmaceutical companies and their hangers-on are spending $5 million a week to block real reform. Suffice it to say that none of these companies have the best interests of the uninsured or the underinsured at heart.

Through its trade group, America’s Health Insurance Programs, the industry is fighting for its life (but not our lives). And so far, it is winning. By “cooperating” with health care “reform” by pledging to eliminate pre-existing conditions as a barrier to coverage, and saying they will take all comers in return for a government mandate that everyone be required to buy its shoddy products, the insurers are poised to reap a massive financial windfall.

So far, the bills in Congress set no limits on what the insurers can charge for premiums, and the legal requirements for covered benefits are likely to be minimal.

If a “reform” bill along these lines passes, it will be a bonanza for insurers, drug and medical device manufacturers, and other players in the medical-industrial complex, all at our expense. Since their revenues are our costs (as patients and taxpayers), there will be no cost containment.

We can prevent another 45,000 Americans from dying next year. An effective cure to the health care crisis is within our reach, and it lies within a single-payer, Medicare-for-All plan. By cutting out private insurance companies, we would not only save taxpayers billions, but deliver quality care to everyone. We shouldn’t have to wait another 12 minutes.

Dr. John Geyman is professor emeritus of family medicine at the University of Washington School of Medicine in Seattle, a past president of Physicians for a National Health Program and author of Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It.

Tales of a Family Doc…..a year later

Bu Aaron Roland, M.D.
DailyKos
Mon Oct 05, 2009

My professional life is full of stories.

There are some of remarkable bravery and happiness: Just last Friday I had the opportunity to trade emails with a patient who, finally, in his 60s (!) has managed to overcome drug abuse, alcoholism, crippling self-doubt, hypertension, and diabetes (yes, he managed to get off all medications!) through hard work and determination. Another, a recently retired Greek American burdened with obesity and its complications, arthritis, diabetes, high cholesterol came in to have me guide his discontinuation of his medicines after his health improved because he returned to a lifestyle “like I used to do in Greece.”

This essay supporting radical transformation of the health care system weaves anecdotes from clinical practice with hard policy analysis. Another version was published here ten months ago, but the passage of time and events demanded an extensive revision. (You may follow me on Twitter @doctoraaron)

doctoraaron’s diary :: ::

And there are some tales full of woe, which can bring me to tears:

About three weeks ago a thirty year old patient whom I had not seen for many years came to my office. He had a large testicular mass, something he ignored until it became painful, not because of youthful imaginations of invulnerability but due to the absence of health insurance.

Now he’s in trouble. Although testicular cancer is one of the most curable cancers, even in advanced stages, treatment is expensive.

And not only is my patient in trouble–bankruptcy is a given–, but the rest of us are in trouble, too.

It would have been so simple, had we a universally available national health program, to treat him with minor outpatient surgery months ago, but now he, and we, are in for the big time.

It makes me want to cry.

The day to day work is full of mundane stories as well, which have their own lessons….

It was 8:50 a.m. when I arrived at my office to find Glenda, my office manager, buried in charts. She’d been there since 6:30, arranging referrals that had been requested the day before, making sure that the detailed forms required by the Child Health and Disability Prevention Program which pays for preventive care provided to some of our poorer patients had been properly completed, and listening to voice mail from pharmacies in order to get medication refill requests for me before the day began in earnest.

Glenda is a great asset to the practice. An extraordinarily hardworking mother of two, four days a week she commutes with her husband from a distant suburb, arriving early to avoid rush hour gridlock and get some work done before the phones start ringing. Having been with me for about ten years, she knows the ins and outs of dealing with all the health plans– which ones require paper referrals, which use the Internet, which force her to hang on the phone waiting for an okay. Only Medicare is easy; all we have to do is provide a patient with the name and phone number of the consultant. MediCal, the California Medicaid program for certain categories of poor people, works the same way in our county but it is a bit more complicated. Not all the consultants we regularly use accept MediCal referrals so the list of available consultants is limited. In her early morning work Glenda joins in what I think of as a game of “hot potato.” The providers, knowing medicine but not the details of each health plan, send administrative work to the staff; Glenda and the rest put their stamp on the process and return work back to the doctors.

The administrative work forced upon medical providers by the private health insurance bureaucracy is almost beyond belief. Indeed, a recent study supported by the Robert Wood Johnson Foundation found that 6.9% of all physician expenses (exclusive of billing costs!) are directly related to burdens imposed by dealing with these corporate bureaucracies.

My own office, a small practice which I own and staff, has grown over the nearly 20 years I’ve been practicing family medicine in the San Francisco suburb of Burlingame. At first I worked alone, delivering babies, assisting at surgery, caring for my hospitalized patients, but always spending most of my time seeing patients in my office across the street from the hospital. Over time, in order to make sure that I could take vacation and to spread the overhead, the practice has expanded and now we are a group of five part time physicians and two nurse practitioners supported by seven full and part time staff. I am in the office four days a week but have managed to work it out so that I am in by 9AM and usually out by 3 or 4PM. The shape of my day is heavily influenced by administrative tasks, however. On a typical day I spend about an hour dealing with tedious, medically unnecessary tasks imposed by insurance companies.

Shortly after I arrive and begin to call patients who’ve left messages overnight Glenda comes by with a small stack of charts that have been giving her trouble. A couple require a short letter from me changing the “diagnosis code” I had used when completing a lab order form. Some insurance companies, it turns out, do not pay for preventive screening tests, so when I order a cholesterol or a prostate cancer screening test at the time of a health care maintainence evaluation, the test might not be covered under a patient’s insurance policy. Fortunately, the lab often catches these slips and notifies us so I can correct the “error”. For better or worse, the two patients whose charts she brings today have elevated cholesterol levels, so I feel honest indicating that fact, knowing that the insurance company will not balk at payment.

In our office we work primarily with two labs which between them are contracted with nearly all the insurance companies we deal with. The hospital-run lab is the most convenient, and we are required to use it for about half of our patients. The other lab must be used by a small fraction of patients. Medicare patients and those with certain PPO insurances, can go to the lab of their choice but choosing one lab rather than another may result in a much larger bill for some patients. For this reason we have a special deal with one lab where we’ve been given a list with prices far lower than they charge patients when they’re billed directly. That way, when we order a test that may not be covered by an insurance policy or if we are serving an uninsured patient, we can collect the discounted price up front and then the lab bills us rather than the patient.

Unfortunately, one of the charts Glenda brings presents a little laboratory headache. Bridget Hanley (her name and the names of all patients in this essay have been changed and the details of medical conditions slightly altered to protect privacy) sent in her 21 year old daughter a few months ago for a routine physical. During the course of the evaluation, a few tests were ordered…. a Pap smear, some S.T.D. tests, a cholesterol test, and two hormone tests. Unfortunately, because her insurance had changed, the “wrong” lab was used and Ms. Hanley got a bill for over $1000. That’s a lot of money to the Hanley family and she is rightly annoyed. I am too: at the lab’s outrageous markups (if we had used our “special deal” the charges would have been only about $200), at a system which forces me to have to consider which lab is “appropriate” for which patient, and at Ms. Hanley. “Isn’t it her responsibility to know which lab her insurance requires her to use?” I think, upset that she was annoyed at me for this mess.

Conservatives argue for the role of personal responsibility in health care. The Hanley family dilemma, and mine, however,is that health care and health care finance, even of the routine variety as in this case, is complex and removes the recipient of services (the patient) from the one prescribing services. In emergency cases, the patient is even less able to participate in choice. This is part of the reason why conservative principles of health care reform are so divorced from reality.

Nevertheless, I sit down and send my second email to the lab director pleading for her intervention in seeking a reduction in charges.

The private health care insurance system which we deal with every day is an insidious bureaucratic monster. The morass of more than 1300 insurance carriers (in my own practice I deal with over one hundred!) in this country introduces an administrative mess beyond belief. Our small office of essentially two full time equivalent providers requires seven support staff to cope with the complexities of this system. I am quite certain that the wasted effort which this system creates is so great that if we had a unified system of health care I could see 10-20% more patients – with two fewer staff. Looked at from another direction, at least 10-20% of my current income is wasted on insurance bureaucracy which benefits no one.

By 9 a.m., the receptionist, Alba, comes in. She is the newest member of our staff, brought in only when our primary receptionist, Evelyn, became ill, requiring extended medical leave for breast cancer treatment at the same time as another staff member was scheduled to be out for maternity leave. So the office is operating a bit understaffed these days. Fortunately, Evelyn’s health insurance is through her husband’s large employer. He works as an animal care technician for a public university medical center. As long as he works they are covered. I try not to think what would happen should budget cutbacks lead him to lose his job. The prospect is frightening for her, for her family of four, and for our office. I certainly would feel obliged to add her to our office health insurance program should this occur. But would the insurance company accept her? What would happen to our premiums? Even assuming no rate increase, adding her to our policy would amount to about a six dollar an hour raise. And what about coverage for her family?

In the ten months that have passed since the first draft of this essay was posted our insurance premiums have risen over ten percent. As a response, I’ve dropped our high quality HMO coverage and have substituted a PPO plan with a large deductible. My hope is that my staff will remain healthy, saving me some money, but I have promised them, in making this switch, that I will cover their deductibles, taking a risk that my own out of pocket expenses will grow significantly.

Another update: Since the original version of this essay was posted Evelyn has remained healthy, free of recurrent breast cancer. Alba, the receptionist who stepped in to fill her place, has moved on, and a new staff member has joined us. This latest member of our staff consulted with me today because of an illness that would usually have led me to order several laboratory tests and an ultrasound. Instead, she and I are going to hold off, hoping the illness will pass on its own as she only recently was rudely awakened to the limitations of a bare-boned insurance policy she shares with her husband and the prospect of more medical bills seemed worse than the anxiety of not knowing just how serious her illness might be…

The receptionist’s job requires verification of each patient’s insurance status, checking lists, looking on-line, and calling for approvals as she confirms insurance eligibility and documents changes. Missing an insurance change can have costly implications for both patients and our practice. Between changes in jobs and employers changing insurance plans to save a few dollars in premiums (as I have recently done), there is a surprising amount of “churn” among health insurance carriers. For Alba, learning the details of this part of her new job was quite a challenge.

The three medical assistants on my staff spend hours daily communicating with patients about medication refills and calling or faxing pharmacies.

Recently we have moved from faxes and phone calls for refills to electronic prescribing. Although we have not seriously considered a wholesale adoption of an electronic medical record, this first step, which would consolidate all our refills in one system and which would eliminate the need for filing seemed worthwhile. It has been a moderately difficult transition, adding to the workload of the providers although reducing the workload of the support staff. Certainly, our experience with this, the easiest and seemingly most cost-effective aspect of the electronic medical record, doesn’t suggest that electronic medical records will lead to any significant savings in health care costs

Most insurance companies allow patients to collect only a one month supply of medication at their local pharmacies (three months if patients can figure out how to manage a mail order program). The rule makes financial sense for insurance companies. Why should one company pay for a year’s supply of medication if a patient may well switch insurance companies or lose their coverage after one month? Unfortunately, the rule doesn’t make sense for patients. Studies show that compliance with chronic medications is abysmally low, in part because of rules like this.

The churn in insurance coverage as people move, change jobs, or suffer economic hardships which lead them to cut back on expenses introduces a huge set of problems for our little office, and wasteful costs for the medical system. Easily half of the new patients we see explain their search for a new doctor (no small task in a community where primary care providers are retiring in far greater numbers than they are starting out) as the result of an insurance change. So we must often “reinvent the wheel”, setting up a new chart, getting to know a patient, revising medications, reviewing old medical records, helping those with complex medical issues reestablish with new consultants. The economic implications for the system are obvious.

A serious related economic issue for our office sprang up last year. One key physician associate decided that she was feeling overwhelmed by her patient load and so decided to close her practice to new patients. This is a more complex and consequential process than it seems. Contracts with insurance providers often require an open practice or establish tiers of payment based upon whether a practice is open or closed. Further, in closing a practice, a wheel begins turning so that the closure is indicated in published listings and on-line resources. This process can be slow and then difficult to reverse. Years ago I had closed my practice for similar reasons. When volume dropped, I attempted to re-open. Some insurance directories, however, lagged in updating these changes for years, leading to much frustration and some degree of financial hardship.

When my associate decided to close her practice, we settled upon closing only to those patients “provided” through our local independent provider association, an organization which manages insurance company contracts for doctors in our area and with which we have a good working relationship. Gradually, over the course of a year her patient panel from this source dwindled from 1200 to 800 patients. At that point, feeling the pinch of lost income to the practice, I asked her to reopen her panel. We are largely paid by capitation, “per member per month,” from these providers so this source of income had dropped by about one third. She was shocked and appalled by my request. Despite the closure of the practice and the substantial loss of income, her workload had declined only slightly. How had this happened?

What we had experienced through this closure was the shock of”adverse selection”. By closing her practice to new patients, my associate lost from her capitation list those patients who bounce in and out of insurance, often healthy and more mobile people who don’t have regular need to see a doctor. With capitation, payment is based upon the number of patients assigned to a doctor rather than upon the nature of the care required. She was left with a group of patients who tended to be the ones who see her more regularly. Hence, less income, same work.

Of course, this process is something that private insurance companies play in reverse. A great deal of insurance company money is spent attempting to avoid patients who could actually require medical services. Underwriting, the process of selecting which individuals and business clients to insure and varying charges based upon assumptions of how much those clients will use their insurance is the backbone of the insurance industry. Marketing, the process of selling insurance, has become a primary tool of this process. Has there ever been an insurance company advertisement that encourages patients with serious chronic illnesses to sign up? Instead, television ads depict elderly men walking on the golf course. The idea is to create a “favorable risk selection”, patients signing up for health insurance who are unlikely to use it, leaving those who need it to some government-provided “safety net” or left to fend for themselves, uninsured.

My first patient of the morning was Uluake Tonga. His English is not great, but we can get along. We have known each other for nearly 20 years. Like most of my Tongan patients (there is a surprisingly large group of this nationality in this part of the San Francisco Bay Area) he comes with a family member who can help him translate. His history is complex, as are his medical needs. Briefly, he has diabetes and most of its complications. Mr. Tonga has never been good at working with the medical system. A hard working airline food preparer at the San Francisco airport, he had for years denied his diabetes. He believed in some natural medications and failed to see me very often. I’d long suspected that the expense of conventional medication was part of the issue as he had insurance of the sort that required him to pay a significant deductible every year and when I took over his care from his previous doctor I noted that his chart had “sent to collections” stamped on it more than once.

Mr. Tonga first faced his diabetes in a serious manner when he was hospitalized for a vision threatening fungal infection. Soon afterwords, because of layoffs in the airline industry, he was without insurance and decided to return to Tonga for a few years. Medical care in Tonga is free and while in the South Pacific he did get care for his diabetes and his blood sugar was finally controlled. Nonetheless Mr. Tonga returned with progressive disease. Now, with kidney failure requiring dialysis, he is better about compliance with his care. Maybe it is because the gravity of his disease is too much to ignore, but I suspect a lot has to do with the fact that his kidney failure now entitles him to Medicare benefits.

Medicare and its cousin, the Veterans’ Administration health system, contrast markedly with the bureaucratic inefficiency and buck passing of the private health insurance system. These systems, which share the fundamental features of centralized funding and near universal enrollment of the populations they serve, have shown that they can provide better quality care and higher satisfaction at a substantially lower cost than the private health system. Within these systems there are no resources spent on achieving a favorable risk selection, marketing, underwriting, investor relations; nor are there corporate profits. As a health care provider, when I deal with Medicare I operate within a clear cut set of rules that applies to all my patients, making referrals, prescriptions, etc. easy to accomplish.

When I see Mr. Tonga, or any of a multitude of other patients whose care has been compromised by the complexities, gaps in coverage, or the increasing unaffordability of private health insurance I wonder about alternatives. Increasingly, I have discussed these alternatives with my patients. During the course of an office visit or speaking to a patient over the phone problems which relate to the inadequacies of the health care system often arise. In a typical day there might be four or five opportunities to discuss issues related to health care reform with my patients. Yet despite the number of different health care financing reform proposals that are bandied about these days virtually all of my patients gravitate towards the same approach: a simple and comprehensive health care plan paid for through taxes and provided through the network of private providers with whom they are familiar. Hundreds of my patients have signed a petition to this effect which I leave to speak for itself in my waiting room.

From my end, as a physician and small business owner, eliminating the multitude of rules, the files of thick contracts, the variations in co-payments, deductibles, and formularies, no longer needing to tell patients that they can’t see the provider I’d recommend because their insurance doesn’t allow it, seems like a dream come true. I want to be confident that my employees have access to quality medical care, that I won’t have to be out shopping for a new plan next month, and that I won’t have to choose between a raise or medical benefits for my medical assistant’s newborn when she returns from maternity leave this winter. (Update: She managed to get insurance through the father’s work!)

But how do we get this done? It doesn’t take much thinking to realize that the only proposal that makes sense to get what is needed is a single payer plan, a Medicare-For-All. Other proposals, health savings accounts, consumer directed health care, managed competition, employer mandates, individual mandates or variations on these themes all promise benefits but suffer from failing to have the potential to achieve true universal coverage and from being hugely expensive because of their reliance upon private health insurance. While some of these variants have been subject to experimentation in the United States (the Massachusetts plan, most notably) only a single payer approach has been shown, in both the U.S. (Medicare) and abroad (throughout Europe and Canada) to work.

In these pages over recent months the dialogue has shifted from advocacy of a single payer system to support for a public option. I have certainly written also in support of a public option. But it is clear to me that anything short of a single payer plan will be destined to fail at achieving anything close to universal coverage and will lack the power to do much to bring health care costs under control.

A publicly financed decentralized system of private health care that is not tied to employment or “category” could eliminate the waste in the bureaucratic private health care system and eliminate the multitude of compartmentalized public and private systems which currently pay for segmented components of health care. Imagine!! No need for Medicaid, MediCal, CHDP, SCHIP; a reduced scope for worker’s compensation insurance, medical liability insurance, and automobile insurance; human resource departments downsized…..the list goes on and on. Essentially, as an improved Medicare for all, this reform would eliminate the distinction between health care for the poor and health care for the rich and reduce the confusion, waste, and annoyance which my office staff and I face in dealing with so many different health insurers.

Something is missing in our political debate over medical care. Over and over again I’ve heard people in power or those writing about the issue support the logic of the argument for single payer reform and then dismiss it without much consideration. Barack Obama has supported this change in theory, but adds that we have to begin from where we are. Jacob Hacker, the Yale and Berkeley political historian who is the intellectual champion of the public option, seems resigned to the observation that fundamental change is just too hard. His Healthcare For America proposal reaches towards a single payer system but undermines its cost-savings and universality by keeping a huge role for private insurancee.

A telling comment came from a member of the President’s Council on Bioethics, during their review of the ethics of health care reform proposals. After commenting favorably on the powerful arguments with which he had been presented he demurred that these were “arguments that we are entirely incompetent to evaluate”. Another commissioner supported the notion of single payer reform but wondered, “if it’s not realistic in this country.” Even among advocates on the progressive side of the political spectrum there is a resigned assumption that single payer is somehow just too much of a change for our country to accept.

From my perspective in the trenches of primary care and small business, however, I can see no other way forward. For my well-insured patients, a switch to single payer will hardly alter the face of the health care system they currently experience. But it will reduce everyone’s level of economic and health insecurity. None will need to worry if something is covered. There will be no more holding on to unsatisfactory jobs simply to keep insured. The process of paying for care will be simplified.

As a small business owner, I won’t have to worry either. Some tax will be paid, a payroll tax, a value added tax, whatever . But there will be no need to agonize over the question of which plan to choose and no more health insurance expense. As I look at my office budget, the $36,144 that I currently spend on employee health insurance is less than the $44,498.97 that I calculate would be owed under a tax of the magnitude contemplated by authors of single payer reforms. But when I add in reduced insurance-generated paperwork, reduced billing costs, lowered malpractice and other insurance premiums, and an increase in my own efficiency, this sounds like a reasonable deal for me as an employer — even without considering the improved care it would give to my patients and the increased mobility it would give to my employees who might seek to improve their lives by changing jobs.

A ray of hope:

Within the current debate there have been two places where I have found a ray of hope for real change. One is in the Kucinich amendment to HR 3200. This amendment, which would remove federal barriers to state enactment of single payer reform, passed the committee with bipartisan support, Republicans backing it perhaps out of a desire for “states’ rights”.

The other ray of hope actually lies in a related reactionary response to the health reform bills in Congress. Around the country Republicans in state legislatures have attempted to pass measures which would outlaw the individual mandate to buy insurance. Although designed to scuttle a crucial aspect of the health reform bills this effort could pave the way for a compromise on the Kucinich amendment, perhaps with a provision that states need not participate in the health reform process as long as they provide an alternative program that secures health coverage for 100% of their citizens.

From where, then, does the political and academic reluctance to embrace single payer reform derive? There would be losers, of course, and this generates some focused opposition. The health insurance business would be essentially eliminated, perhaps surviving as a remnant to serve as a data collection and money disbursement system. Pharmaceutical companies and medical device manufacturers might feel the pinch of tough negotiations from a central purchasing center. But the interests of patients and health care providers of all sorts are sufficiently aligned that having a single payer should not prevent us from getting the health care that we need. Certainly the experience of other developed nations with national health insurance supports this conclusion.

The last great attempt at achieving a major overhaul of our national health insurance system– the Clinton administration’s reform effort– foundered for many reasons: It was developed among a group of interested parties, largely outside of the public eye, creating the impression that it was beholden to “special interests”. The plan was immensely complex and required the creation of new agencies to oversee the program which could be portrayed as “big brother”-like control. This, together with provisions that employers must purchase private insurance for employees raised fears about potential costs. Small business owners who have increasingly avoided purchasing health insurance for employees perceived themselves to be losers, while already insured employees in larger businesses feared the specter of managed competition and the reform proposal’s focus upon cost control would result in lower quality and reduced choice.

The wheel has turned, and President Obama has taken a more open approach to health care reform. Yet though the crisis has deepened, and the solution seems clearer to those who understand the fundamental failings of our existing system, I am sadly doubtful that we are moving in the right direction. The openness has let powerful private economic interests take control of the reform process. In the next few weeks we will get a glimpse of what may be to come. Let’s keep pushing for and speaking the truth.

Peace,

Aaron Roland, M.D.
Twitter@doctoraaron

http://www.dailykos.com/storyonly/2009/10/5/774580/-Tales-of-a-Family-Doc…..a-year-later

What is the right penalty to enforce an individual mandate?

Give people breathing room

By Sen. Charles E. Schumer
USA Today
October 8, 2009

Sen. Olympia Snowe of Maine and I decided to give some breathing room to families faced with the uneasy choice of buying insurance they can’t afford or paying a stiff penalty that they also can’t afford. Our proposal, which passed the Senate Finance Committee 22-1, exempts Americans from the requirement to buy insurance if the cost of the available plans exceeds 8% of their income. We also reduced the amount of the penalty and phased it in over time, to make sure the reformed system works before we punish people for not participating.

http://blogs.usatoday.com/oped/2009/10/opposing-view-give-people-breathing-room.html#more

And…

CBO Understates Major Impact Of Weakened Individual Mandate

BlueCross BlueShield Association
October 7, 2009

It is difficult to understand why the Congressional Budget Office (CBO) estimate did not show a greater impact from the significant weakening of the mandate in the amended bill. Amendments approved during the Senate Finance Committee mark-up eviscerated the individual mandate — completely eliminating it in 2013, significantly lowering penalties to the point that it will only represent about 15 percent of the cost of a premium by 2017. Further, many individuals would be exempt from the penalties altogether. This is likely to result in millions of people foregoing coverage.

http://www.bcbs.com/news/bcbsa/cbo-understates-major-impact-of-weakened-individual-mandate.html

Comment:

By Don McCanne, MD

The current reform proposal before Congress would encourage more uninsured individuals to purchase health care coverage by assessing a financial penalty on those who fail to do so, thus enforcing an individual mandate to purchase insurance.

As Senator Schumer states, if that penalty is too high, those who can’t afford the insurance premium wouldn’t be able to afford the penalty either. Thus the Senate Finance Committee passed an amendment that offers these individuals and families “breathing room” by granting them the right to remain uninsured by paying a more modest penalty than previously proposed. That penalty might still be a hardship for many, but worse would be the hardship of having no health insurance al all.

BlueCross BlueShield Association points out that these lower penalties would likely result in millions of people foregoing coverage. That would risk adverse selection in which individuals who need health care would buy the plans, and the healthy would opt out as long as their health care needs were minimal. That would drive up premiums, making the plans even less affordable. Worse (strictly from the private insurers’ perspective) is that would knock out a significant portion of the market that they are attempting to capture.

So what is the proper balance to achieve optimal benefit from the penalty under the individual mandate? Students of George Lakoff will recognize that we have here a problem with framing. Members of Congress have decided that their preferred solution to the problems of coverage and affordability is that everyone not eligible for public programs must purchase private health plans. This framing eliminates more effective solutions and excessively limits the policy options. Seeking the proper balance for the mandate penalty leads to a dead end since there is no proper balance. The flaw is not in the penalty. The flaw is in the mandate to purchase unaffordable private plans.

We can help Congress with framing that will lead to the reform that we need, but will they ever be willing to listen?

Colorado Information

Chapter Organization

As of early 2018, Colorado has a newly chartered statewide chapter, PNHP-CO. We believe that we have the best chance in decades to pass national single-payer health care reforms, and that Colorado physicians advocating for a true single payer system can play a key role in making that happen.

An ad hoc steering committee is meeting to decide on our first steps. We will be reaching out to current and former PNHP members across the state in the near future.

Contacts

ColoradoCare Ballot Initiative

An initiative to amend Colorado’s constitution and create a taxpayer-funded health insurance cooperative (ColoradoCare) was on the state’s ballot in 2016. It did not pass. PNHP has a short analysis of ColoradoCare here.

Local Unions Endorsing Single Payer

  • Boulder Area Labor Council
  • District Council 1, International Union of Painters and Allied Trades, IUPAT

Montana Information

There are currently no active chapters in this state. If you would like to start a new PNHP chapter, or are looking for additional ways to get active, please email our organizing team at organizer@pnhp.org.