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Comment by Ray Bellamy, MD

http://prescriptions.blogs.nytimes.com/2009/09/19/medicare-for-all-crazy-socialized-and-unlikely/#comment-28137

Prescriptions Blog
New York Times
September 20, 2009

Katharine Q. Seelye really got it all wrong with her analysis of the finances of Medicare for All. Some of the reasons for Medicare’s financial difficulties come readily to mind:

1. Bad Risk Pool of the elderly (think end of life care), and the disabled (think sick).

2. Financing has not changed since 1985. How can funding for healthcare for the sickest of our population be sustained over 24 years of increasing healthcare costs without raising the Medicare tax?

3. Political interference. Effectiveness recommendations have been blocked by Congress, who have mandated coverage for treatments of dubious benefit such as chiropractic and complementary medicine to please constituents. Providers, one who bilked Medicare and was fined over a million dollars twice, are still providers due to political interference. The savings of Medicare for All would be 380 billion dollars or more a year, according to independent analyses, and this is enough to easily extend comprehensive coverage to ALL of the uninsured and have money left over for reducing the deficit. The inclusion of healthy, lower cost younger folks in the risk pool of all Americans spreads the risk and cost along with massive administrative savings. There are additional huge benefits in better effectiveness data to improve quality, as well as identification of overutilization and better cost control by global budgeting and volume discounts. Congress and America would benefit by a head-to-head comparison by an independent agency such as the CBO or other comparing Single Payer with any other proposal you want to offer. Single Payer would win hands down, as the rest of the developed world has already figured out.

Comment by Ray Bellamy, MD

http://prescriptions.blogs.nytimes.com/2009/09/19/medicare-for-all-crazy-socialized-and-unlikely/#comment-28137

Prescriptions Blog
New York Times
September 20, 2009

Katharine Q. Seelye really got it all wrong with her analysis of the finances of Medicare for All. Some of the reasons for Medicare’s financial difficulties come readily to mind:

1. Bad Risk Pool of the elderly (think end of life care), and the disabled (think sick).

2. Financing has not changed since 1985. How can funding for healthcare for the sickest of our population be sustained over 24 years of increasing healthcare costs without raising the Medicare tax?

3. Political interference. Effectiveness recommendations have been blocked by Congress, who have mandated coverage for treatments of dubious benefit such as chiropractic and complementary medicine to please constituents. Providers, one who bilked Medicare and was fined over a million dollars twice, are still providers due to political interference. The savings of Medicare for All would be 380 billion dollars or more a year, according to independent analyses, and this is enough to easily extend comprehensive coverage to ALL of the uninsured and have money left over for reducing the deficit. The inclusion of healthy, lower cost younger folks in the risk pool of all Americans spreads the risk and cost along with massive administrative savings. There are additional huge benefits in better effectiveness data to improve quality, as well as identification of overutilization and better cost control by global budgeting and volume discounts. Congress and America would benefit by a head-to-head comparison by an independent agency such as the CBO or other comparing Single Payer with any other proposal you want to offer. Single Payer would win hands down, as the rest of the developed world has already figured out.

By T. R. Reid
NEWSWEEK
Published Sep 12, 2009

“Us Canadians, we’re kind of understated by nature,” Marcus Davies told me in his soft-spoken way. “We don’t go around chanting ‘We’re No. 1!’ But you know, there are two areas where we feel superior to the U.S.: hockey and health care.”

Davies is an official of the Saskatchewan Medical Society, so it’s not surprising that he would want to extol Canadian medicine. But that feeling of patriotic pride in the nation’s health-care system is something that just about all Canadians share. They love to point out that Canada provides coverage for everybody, usually with no copay and no deductible–while the U.S. leaves tens of millions of its citizens uninsured. They love to remind us that, while the U.S. lets some 700,000 people go bankrupt due to medical bills each year, the number of medical bankruptcies in Canada is precisely zero.

Yet I wasn’t inclined to let Davies go unchallenged. I agreed that Canada does an admirable job of providing free and prompt care to anybody with an acute medical condition. But for nonemergency cases, the system often provides nothing but a long wait. Last summer I tried to get an appointment with an orthopedist in Canada to treat my aching right shoulder; the waiting time, just for an initial consultation, was 10 months. How could you be proud of that?

“You’re right,” Davies said frankly. “We keep people waiting, to limit costs. But you have to understand something basic about Canadians. Canadians don’t mind waiting for elective care all that much, so long as the rich Canadian and the poor Canadian have to wait about the same amount of time.”

In that last sentence, Davies set forth the national ethic of health care in his country: medicine is not a commodity to be sold to the highest bidder, but a right that must be distributed equitably to one and all. In short, the Canadians have built a health-care system that neatly fits the Canadian character: ferociously egalitarian, but thrifty at the same time.

I found that same pattern–a health-care system that reflects a nation’s basic cultural values–everywhere I went when I traveled the world for a PBS documentary and a book about how other wealthy countries provide health care. “The fundamental truth about health care in every country,” notes Princeton professor Uwe Reinhardt, one of the world’s preeminent health-care economists, “is that national values, national character, determine how each system works.”

The design of any country’s health-care system involves political, medical, and economic decisions. But the primary issue for any health-care system is, as President Obama made clear last week, a moral question: should a rich society provide health care to everyone who needs it? If a nation answers yes to that moral question, it will build a health-care system like the ones in Britain, Germany, Canada, France, and Japan, where everybody is covered. If a nation doesn’t decide to provide universal coverage, then you’re likely to end up with a system where some people get the finest medical care on earth in the finest hospitals, and tens of thousands of others are left to die for lack of care. Without the moral commitment, in other words, you end up with a system like America’s.

Around the world, cultural influences govern much of the nitty-gritty of daily medical practice. In the Confucian nations of East Asia, doctors were traditionally expected to treat people for free; they earned a living by selling medicine to be taken once the patient went home. To this day, doctors in Japan and China do both the prescribing and the selling of medicine. And guess what? Those doctors tend to prescribe far more drugs than their Western counterparts, who don’t share in the pharmacy’s profit.

British women tend to have their babies at home; American women tend to deliver in the hospital, but go home a day or two after the birth; Japanese women remain in the hospital with the baby an average of 10 days after delivery. In Britain, Spain, and Italy, the basic rule of medicine is that people never get a doctor’s bill; health care is funded through general taxation. But just across the border, in France, patients are expected to make a cash payment for any encounter with the health-care system, even though the insurance plan will reimburse most of that copay within a week or so. The French have decided that people should be reminded on every visit that health care costs money–even if it’s the insurance company’s money.

In Germany and Austria, health insurance pays for a week at a spa, if a doctor prescribes it to deal with stress. In Britain, when I asked whether the National Health Service would provide the same benefit, my doctor laughed at the very thought of it.

But the most important influence of national culture can be seen in the most basic question facing any country’s health-care system: who is covered?

On this fundamental issue, the United States is the odd man out among the world’s advanced, free-market democracies. All the other industrialized democracies guarantee health care for everybody–young or old, sick or well, rich or poor, native or immigrant. The U.S.A., the world’s richest and most powerful nation, is the only advanced country that has never made a commitment to provide medical care to everyone who needs it.

Our lack of universal coverage has consequences. According to government and private studies, about 22,000 of our fellow Americans die each year of treatable diseases because they lack insurance and can’t afford a doctor. This generally happens to people with a chronic illness who have too much money to qualify for Medicaid, but too little to pay for the drugs and treatment they need to stay alive. Among the rich nations, this happens only in America. Likewise, the U.S. is the only developed country where medical bankruptcies can happen.

Those Americans who die or go broke because they happened to get sick represent a basic moral decision our country has made. All the other rich countries have made a different decision: they cover everybody. A French physician, Dr. Valerie Newman, explained it this way: “You Americans say that everybody is equal,” she said. “But this is not so. Some are beautiful, some aren’t. Some are brilliant, some aren’t. But when we get sick–then, yes: everybody is equal. That is something we can deal with on an equal basis. This rule seems so basic to the French: we should all have the same access to care when it comes to life and death.”

Other nations adhere to the same principle, with slightly different explanations. For Switzerland–a rich, capitalist country that didn’t create a universal health-care system until 1994–the underlying rationale is the concept of solidarite. That’s a crucial word in the Swiss vocabulary, freighted with meanings that include “community,” “equal treatment,” and “despite our differences, we’re all in this together.”

“To have a great sense of solidarite among the people,” former Swiss president Pascal Couchepin told me, “all must have an equal right–and particularly, a right to medical care. Because it is a profound need for people to be sure, if they are struck by the stroke of destiny, they can have a good health system.”

That principle seems so obvious to people in Europe, Canada, and the East Asian democracies that health officials asked me over and over to explain why it isn’t obvious to Americans as well. “The formula is so simple: health care for everybody, paid for by everybody,” a deputy health minister in Sweden told me. “You Americans are so clever. Why haven’t you figured that out?”

This formula is so basic in the other industrialized democracies that virtually all of them have included some version of a “right to medical care” in the national constitution. Nearly all European countries (the striking exception is Russia) have signed on to the European Union’s Charter of Fundamental Rights, which serves as a sort of continentwide Bill of Rights, enforceable by the courts. “Everyone has the right of access to preventive health care and the right to benefit from medical treatment,” the charter says.

The new democracies that have emerged in the two decades since the fall of the Soviet Union generally include a “right to health care” in their constitutions. The Czech Constitution, written in 1992, is typical. “The state is obliged to guarantee the right to life and the right to protection of health, and health care for all,” the document declares.

In the U.S., in contrast, neither the federal Constitution nor any state guarantees “health care for all.” Some Americans have gone to court claiming a right to care. The legal theory is that our Declaration of Independence says we all have “inalienable rights,” including a right to life, and you can’t have life without medical care to keep you alive. No U.S. court has ever bought this argument.

In the other advanced democracies, though, there’s no debate. All of them recognize a right to “health care for all” as a moral obligation. But they don’t all agree on the way to assure that right.

Some nations–Britain, Spain, Italy, and New Zealand, among others–have decided that providing health care is a job for government, just like building roads or putting out fires. In those countries, government owns the hospitals, employs many or most of the doctors, and pays the bills. That seems pretty close to what Americans think of as “socialized medicine.”

But many rich democracies–Germany, France, Switzerland, the Netherlands, Japan–provide universal coverage with private doctors, private hospitals, and mainly private insurance plans. Unlike Americans, who switch to government-run insurance (Medicare) at age 65, Germans stick with private insurance from cradle to grave. Japan has more for-profit hospitals than the U.S., and far fewer doctors on the government payroll than we do. This is universal coverage, but it’s not socialism.

Some countries–Canada, Taiwan, Australia–have a blended system, with private-sector doctors and hospitals, but a government payment system. The Canadian model–private providers, but public insurance to pay them–is the system Lyndon Johnson copied when he created Medicare in 1965. The difference is that Canada, Taiwan, and Australia provide the public insurance for everybody, while the U.S. restricts it to seniors and the disabled.

In our current debate on health care, many have warned that universal coverage will inevitably lead to “rationing” of health care. The argument overlooks a basic fact: the United States already rations health care. Indeed, every country rations health care, because no system can afford to pay for everything. The key distinction is the way rationing happens.

In the other developed democracies, there’s a basic floor of coverage that everybody is entitled to; that’s why nobody dies in those nations for lack of care. But there are limits on which procedures and which medications the system will pay for. That’s where the rationing kicks in. “We cover everybody, but we don’t cover everything,” the former British health minister John Reid explained.

In the U.S., in contrast, some people have access to just about everything doctors and hospitals can provide. But others can’t even get in the door (until they are sick enough to need emergency care). That amounts to rationing care by wealth. This seems natural to Americans; to the rest of the developed world, it looks immoral.

“Canadians don’t mind waiting for elective care all that much, so long as the rich Canadian and the poor Canadian have to wait about the same amount of time.” In that one sentence, Marcus Davies laid out the ethical basis of Canada’s health-care system. The question facing Americans this fall is: what should be the ethical basis of America’s health-care system?

Reid’s Book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care was just published by Penguin Press. He was the Correspondent for Two PBS Frontline documentaries based on the book.Reid’s The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

Find this article at http://www.newsweek.com/id/215290

(c) 2009

By Russell Mokhiber
SinglePayerAction.org
September 21, 2009

Single payer activists have set up a memorial on the National Mall for the more than 44,000 Americans who die every year from lack of health insurance.

The memorial is being sponsored by Physicians for a National Health Program and Single Payer Action.

More than 3,000 American flags are planted on the mall at Constitution Avenue and 15th Street, NW, Washington, D.C.

The memorial is framed by a large, colorful banner that reads: “Every day, 120 Americans die from lack of health care. It doesn’t have to be this way. Single payer now. Everybody in. Nobody out.”

Tourists from Denmark, Israel and other foreign countries were stunned by the death toll.

“We don’t have this in Israel,” said one Israeli tourist. “Nobody dies from lack of health insurance. We have other problems.”

A Danish tourist said — “I’m from Denmark. We don’t have this problem there.”

“Each flag represents ten American deaths,” said Dr. Margaret Flowers of Physicians for a National Health Program. “Every day, we will plant 12 additional flags — representing the 120 Americans who died that day from lack of health insurance.

“We hope that this will make the deaths, which aren’t reported regularly in the papers, visible to the public and our legislators.”

“We feel a sense of urgency, because of the growing number of preventable deaths, to pass legislation that will be truly universal and control health care costs: a publicly financed national health system often referred to as ‘single payer’. We don’t see that happening currently in Congress,” Flowers said. “It is time to join the rest of the industrialized countries, to do what civilized societies do — take care of their people. We spend the most money on health care and have poor health results. Sooner or later, we will get single payer. We’re working to get it sooner — to save lives.”

A study published in the American Journal of Public Health last week found that more than 44,000 Americans die every year — 122 every day — due to lack of health insurance.

The 44,000 dead a year estimate is about two-and-a-half times higher than an estimate from the Institute of Medicine in 2002.

The Harvard-based researchers found that uninsured, working-age Americans have a 40 percent higher risk of death than their privately insured counterparts, up from a 25 percent excess death rate found in 1993.

“In Canada and western Europe, the number of people who die every year from lack of health insurance is zero,” said Russell Mokhiber of Single Payer Action. “In the United States, it’s 44,000. That’s a disgrace. It doesn’t have to be this way.”

Even the most liberal health care reform bill being seriously considered by the Democrats in the House would leave 17 million people uninsured.

The bill proposed by Senator Max Baucus would leave 25 million uninsured.

That translates into about 25,000 deaths annually from lack of health insurance.

“Single payer saves lives,” Mokhiber said. “Let’s get it done.”

Mark Dudzic of the Labor Campaign for Single Payer said he’s volunteering at the memorial because “it’s important to bear witness to all of the lives that have been lost because we’re the only industrialized country that doesn’t have a humane health care system for its people.”

The memorial will be up all of this week — until 6 p.m. on Sunday, September 27, 2009.

If you would like to volunteer at the memorial, write to Dr. Margaret Flowers at mdpnhp@gmail.com

By Faye Flam
Philadelphia Inquirer
Sun, Sep. 20, 2009

When politicians and pundits speak of “a slippery slope to socialism” and “government takeover of health care,” they’re using terms straight from the industry PR machine, said Wendell Potter.

He should know, he said, because he once crafted them for insurance giant Cigna Corp.

Potter, 58, quit his job as chief of corporate communications in 2008 and now spends much of his time doing radio and television interviews and consulting with the Center for Media and Democracy in Washington.

Addressing about 200 people at the Free Library of Philadelphia yesterday, Potter gave his insider’s perspective on the power of the insurance industry and its well-funded battle to weaken the health-care bills in Congress.

The event, billed as a town hall, was sponsored by Physicians for a National Health Program and several other nonprofit groups that advocate for public-health reform.

For 15 years, Potter worked at Cigna headquarters in Two Liberty Place, where he helped deal with media inquiries, sometimes regarding horror stories of coverage denial. In one high-profile 2007 case, a leukemia patient died awaiting a liver transplant that Cigna initially refused to pay for.

About the same time, Potter said, he was swayed by Michael Moore’s 2007 documentary, Sicko, which Potter considered well-done and accurate. “And I knew I would be asked to be part of an effort to discredit it,” he said.

Soon afterward, he took a trip to a rural “health fair” in Wise, Va., where he saw thousands of people lined up to get free care provided by charity because they couldn’t afford a doctor. Many of them had insurance.

He said that without reform, the trend would continue toward less coverage and higher premiums, especially through so-called consumer-directed health plans. One such plan being marketed by an insurance group would have a $20,000 deductible, Potter said.

Meanwhile, he said, industry public-relations people use linguistics and message research to find that “simple terms like government takeover will scare the bejesus out of people.”

Through such slick PR and manipulation of public discourse, the industry is waging an insidious battle against serious health-care reform, he said. As evidence, he pointed to last week’s widely anticipated bill from Sen. Max Baucus (D., Mont.).

“It’s a gift to the insurance industry,” Potter said. “They got more than they ever could have dreamed of.”

The mention of Baucus quickly drew boos from the audience.

The Baucus bill has no provision for a public-option insurance plan that the government would offer to compete with private plans. Potter said such an option would likely prove more affordable for small businesses and individuals because administrative costs would be lower and the government would not need to answer to investors on Wall Street.

If a public option is put into the final bill, he said, the insurance industry will fight to make it available to as few people as possible.

The audience offered cheers of support, though one man near the back protested as Potter told an anecdote about foreign journalists who were shocked that Americans put up with such a health-care system.

“You made it that way,” the man interjected. He also called it “outrageous” that Potter was not being held accountable for all the money he made working for an industry he now campaigns against.

Asked Friday to comment on some of the former executive’s assertions, Cigna’s new corporate communications chief, Chris Curran, issued a written statement: “At Cigna, we strongly support comprehensive health-care reform with the goal of expanding access, controlling costs, and improving the quality of care. Although we respect that there are different opinions on the solutions, we strongly disagree with the suggestion that, motivated by profits, the insurance industry has deliberately attempted to confuse or unfairly treat covered individuals.”

No one rose to the defense of the industry at yesterday’s meeting, though the man who had objected earlier continued to protest the way Potter had enriched himself at Cigna.

Potter took it on. “It’s a valid question,” he said. “I get that a lot. . . . I was a flawed person.”

Fairness & Accuracy in Reporting
9/22/09

Action Alert

The New York Times devoted some rare space on September 20 to discussing single-payer (or Medicare-for-all) health reform. The result? A one-sided account of why such a system couldn’t work.

With a headline like “Medicare for All? ‘Crazy,’ ‘Socialized’ and Unlikely,” readers probably had a sense of what the Times had in mind with the piece, which was the latest in a series titled “Prescriptions: Making Sense of the Healthcare Debate.” Reporter Katharine Seelye wrote: “Extending Medicare to all has seemed like a good idea to many–except to those who call it ‘socialized medicine.’ Or crazy.”

The Times seemed to want to express single-payer opposition in more gentle tones, explaining that the idea is, from the start, politically impractical: “Beyond a liberal base in the House, there is little support for expanding Medicare.” And outside of Congress, wise minds seem to agree: “But even experts of diverse ideological views say expanding Medicare would be far more complicated and politically difficult than it might appear.”

That led to the first claim: “For one thing, they say, Medicare reimburses doctors and hospitals at much lower rates than private insurance companies do. So, in general, healthcare providers oppose extending Medicare because they fear being driven out of business.” It’s not clear how serious this fear might be, since most doctors participate in the Medicare system without going bankrupt. Any attempts to reduce the skyrocketing costs of the healthcare system involve cuts of one form or another; most single-payer proposals discuss how to do this without shortchanging physicians. (U.S. doctors make, on average, almost three times the median physician salary in other wealthy industrial countries–Ezra Klein, 4/19/06.)

It’s worth noting that thousands of doctors have voiced support for a single-payer system (see, for example, Physicians for a National Health Program’s letter to Barack Obama), in part because they believe they spend too much on the administrative costs associated with private insurance companies. A survey of physicians published in the Annals of Internal Medicine (4/1/08) found that 59 percent supported government-sponsored national health insurance.

Seelye also wrote that Medicare for all “would almost certainly mean a big tax increase on the middle class,” before noting in parentheses: “Supporters argue that a tax increase would be somewhat neutralized by the elimination of premiums that people pay now to insurance companies.” Actually, single-payer advocates argue that a payroll tax on businesses (many of which currently pay for private insurance for their employees) and a small income tax increase that would likely amount to less than what most citizens currently pay out of pocket could fund a single-payer program. By calling a “big tax increase” a near-certainty and treating the savings on insurance premiums as a claim made by advocates, the Times told readers which side it was on.

Seelye cited Stuart Altman–identified as “a Brandeis economist who specializes in health care and who advised Barack Obama in his presidential campaign,” but not as a director of a managed-care company that offers health insurance plans (WhoRunsGov.com)–to make a similar point about potential tax increases, and then went to “the other end of the political spectrum” to quote Robert Moffit of the conservative Heritage Foundation: “I don’t see popular support for it beyond liberals…. It’s a philosophical question: Do you want to give the government that kind of power?”

Of course, one might point out that public polling for years has demonstrated that support for single-payer is much broader than merely a liberal sliver of the population (FAIR Action Alert, 3/12/09); a July 2009 tracking poll from the Kaiser Family Foundation found 58 percent support for Medicare for all. But a piece detailing the deficiencies of a “crazy” single-payer system is an unlikely venue for that.

Seelye quoted Moffit saying that single-payer “would not save taxpayers money,” while another academic suggested it would “require a tripling in payroll taxes just to pay hospitals alone.” These are stark claims that are at odds with the research of single-payer advocates and experts. Physicians for a National Health Program, for example, calculate the annual savings on administrative paperwork under a single-payer system at more than $350 billion. International surveys of health systems generally show that nations that have adopted public plans spend far less than the U.S., and achieve better results (BMJ, 5/26/07).

So why couldn’t the Times quote sources who would take issue with these claims? From the looks of it, balance wasn’t the point here. The Times collected a litany of criticisms of single-payer healthcare–in effect rebutting claims that the paper rarely allows its advocates to make in the first place.

ACTION:
Ask New York Times public editor Clark Hoyt why the Times ran a piece devoted to undermining the case for single-payer healthcare without allowing advocates to make the case in support of Medicare for all.

CONTACT:
New York Times
Clark Hoyt, Public Editor
public@nytimes.com
Phone: 212-556-7652