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By Robert G. Evans.
Journal of Health Politics
Vol. 22. No. 2, April 1997

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Abstract

Political conflict over the respective roles of the state and the market in health care has a long history. Current interest in market approaches represents the resurgence of ideas and arguments that have been promoted with varying intensity throughout this century. (In practice, advocates have never wanted a truly competitive market, but rather one managed by and for particular private interests.) Yet international experience over the last forty years has demonstrated that greater reliance on the market is associated with inferior system performance–inequity, inefficiency, high cost, and public dissatisfaction. The United States is the leading example. So why is this issue back again? Because market mechanisms yield distributional advantages for particular influential groups. (1) A more costly health care system yields higher prices and incomes for suppliers–physicians, drug companies, and private insurers. (2) Private payment distributes overall system costs according to use (or expected use) of services, costing wealthier and healthier people less than finance from (income-related) taxation. (3) Wealthy and unhealthy people can purchase (real or perceived) better access or quality for themselves, without having to support a similar standard for others. Thus there is, and always has been, a natural alliance of economic interest between service providers and upper-income citizens to support shifting health financing from public to private sources. Analytic arguments for the potential superiority of hypothetical competitive markets are simply one of the rhetorical forms through which this permanent conflict of economic interest is expressed in political debate.

“Going for the Gold: The Redistributive Agenda behind Market-based Health Care Reform,” Journal of Health Politics, Policy and Law, Vol. 22. No. 2, April 1997.

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Letter to the Editor
Honolulu Advertiser
July 15, 2009

Health care

President Obama has said he wants health care reform that does three things: reduces costs, ensures free choice of providers for patients and ensures universal access. He also said we need to “build on what works” in health care and, “If you’re happy with the insurance you have, you can keep it.”

However, the only ones who are happy with their health insurance these days are the ones who have not had to use theirs recently. If Obama really wants to know what is not working, he should spend an hour reading some of the thousands of “Health Care Stories for America” submitted to his own Web site. They add up to a devastating indictment of the health insurance industry. The for-profit health insurance industry is not “what works,” it is the cancer that is killing U.S. health care and driving its cost into the stratosphere.
The only reform that will actually achieve Obama’s goals of reduced cost, free choice and universal access is more than just a “public option,” it is single-payer public financing of private care delivery and elimination of the U.S. health insurance industry.

Stephen Kemble, MD
Honolulu

Letter to the editor
Milwaukee Journal-Sentinel
July 14, 2009

People who believe a public option will make health insurance companies and health maintenance organizations more accountable should look at Medicare’s Part C Medicare Advantage privatization option. Forbes found insurance companies and HMOs cherry-picking healthy seniors for their plans and lemon-dropping sickly seniors into Medicare Parts A and B.

One goal of health insurance reform should be to broaden the pool to spread and reduce risk. By insuring everyone, single-payer health insurance would be the largest possible insurance pool. No more slicing and dicing of Americans into market shares: middle class (health insurance companies and HMOs), uninsured (potential public option enrollees), old (Medicare), poor (Medicaid), etc.

The naysayers say there is little support for single-payer health insurance, but no Republican probably will campaign to abolish Medicare Parts A and B (single-payer health insurance for seniors) in the 2010 midterm election. The health care sector contributed $167 million to candidates in last year’s election. Congress and President Barack Obama should overcome their addictions to campaign contributions and pass and enact S. 703 and H.R. 676 to ensure every American good, affordable health care and the freedom to choose our doctors.

Daniel Lee
Milwaukee

By RICHARD PROPP
Times Union (Albany, NY)
Thursday, July 9, 2009

Hippocrates, the famous Greek physician, stated in his oath that “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”

It is well to remember these cautions as we look to the healing of our health care non-system, particularly when studying proposals for a public option, as contrasted with single payer.

A public option means you may purchase insurance from a separate government- or non-profit-run insurance program as an alternative source of health care financing. It leaves the private insurance industry in place to conduct business as usual.

Private insurance companies adamantly oppose a public option because they contend it will expose them to unfair low-overhead competition. Public option folks adamantly support it, saying that it will provide insurance to many who might be uninsured and that it is “politically feasible.” A public option is far from being a tax-supported privately run single-payer health care system. In fact, the public option would only add to the cost and complexity of administration, billing and collecting. It leaves the thousand or so private health insurance company systems and their exorbitant overheads and draconian policies intact. As such, it is just the latest example of incremental reform.

In his 2008 book, “Healthcare, Guaranteed,” Ezekial Emanuel, now health care advisor to the Office of Management and Budget, stated; “Setting concrete goals for a new American health care system is vitally important, but it is perhaps more important that citizens find the courage to demand comprehensive reform of the system. Our system is so fundamentally and irreparably flawed that incremental health care reform can only exacerbate the chaotic and exorbitantly expensive services we receive today.”

We accept the premise that all are entitled to police and fire protection, and that quality education is a right for all children. Health care is a necessity as well. Should health care be afforded the same stature?

This is the crux of the problem, and the American people must decide whether they want health care to be a right.

If so, a gradual expansion of an improved and refocused Medicare system, implemented in age groups of five years at a time, would be a relatively simple way to accomplish it.

Other parts of the system also need change, such as the cost of a medical education. The only downside would be a decrease in private insurance company profits and politicians’campaign chests.

Is that what we are afraid of?

Challenge your representatives If they don’t support real health care reform, vote them out. But do not settle for something under the guise of “reform” that will just make things worse. And don’t be fooled by proposals like the insurance mandate that is plaguing Massachusetts and inflicting real financial pain on ordinary people.

It takes courage and tenacity, but in the long run, it will be worth it to hold out for real reform — an American single-payer health system, funded by the government and run by private physicians and hospitals.

Richard Propp, M.D., of Albany is chair of the Capital District Alliance for Universal Healthcare.

Rose Ann DeMoro
The Guardian
Thursday 9 July 2009

With Barack Obama in the White House, large Democratic majorities in Congress, and a relentless focus in Washington on healthcare, this could have been the year the US finally joined the community of nations which guarantee healthcare for all their people.

But despite the alignment of these political stars, the escalating financial meltdown of the US healthcare system, and numerous polls showing overwhelming public support for systemic change, it looks like the opportunity could be lost again.

To be sure, something should be signed: “We’re going to make it happen this year,” President Obama repeated in a town hall meeting on 1 July. But at the price of accommodating conservatives in Congress, corporate interests, and the healthcare industry, Obama and the Democrats are poised to leave the private insurance system, largely responsible for the present crisis, entrenched in place.

Unlike many of his predecessors, President Obama has even praised the national health care systems that are second nature to citizens of the UK and other industrialised countries.

But, although Obama a few years ago described himself as an advocate of a “single payer” option — a system like Medicare in which the government pays all the bills but care remains delivered by mostly private doctors, hospitals, and clinics — now he and Congress have slammed the door on considering that approach.

When pressed by leading groups of nurses, doctors and thousands of grassroots activists who have campaigned for single payer, the president says, as he did again on 1 July, that it would be “hugely disruptive,” and that “we should … find a way to create a uniquely American solution to this problem.”

Of course, the US already has a “uniquely American” system — the reason for the disgraceful World Health Organization standings that place the US down in 37th place in its overall rankings, and an embarrassing 54th in healthcare “fairness”, barely edging out the impoverished African nations of Chad and Rwanda, but still behind Bangladesh.

While those other countries have a variety of approaches, the US has the distinction of being “the only nation on earth that barters human life for money,” as Geri Jenkins, RN, co-president of the nation’s largest nurses’ union, the California Nurses Association/National Nurses Organizing Committee, put it in recent testimony to Congress.

A system in which mostly for-profit insurance companies can dictate what coverage people get, deny medical care even when recommended by the patient’s doctor, and charge as much as they want.

The upshot is some 45 million people uninsured, 20,000 deaths annually due to lack of coverage, medical bills accounting for 62% of bankruptcies, half of all Americans skipping doctors visits or immunisations for their children because of high out-of-pocket costs, and a system less fair than Bangladesh.

Tragically, the basic structure behind these grim numbers will probably be preserved by the bill expected to emerge from Congress.

After considerable concessions to the healthcare industry and other corporate powers who dominate the legislative system through campaign contributions and other influence peddling, the principle terms will presumably include:

— a mandate on everyone now uninsured to buy private insurance or face financial penalties;

— public subsidies for those on low and moderate incomes to buy that insurance, amounting to a pass-through, or massive public bailout, to an insurance industry whose 18 largest companies recorded over $44bn in profits over the past three years;

— requirements that insurers finally agree to sell policies to people who have been ill in the past or are considered candidates for future health problems (a circumstance that would bewilder people in other countries);

— and, possibly, a public plan alternative for some, though fierce opposition from the insurers and Republicans makes this provision likely to be substantially eroded or eliminated.

Missing from this picture are serious cost controls that limit what insurers can charge — premiums alone have gone up four times faster than personal incomes in the US the past decade — and any expectation that private insurers will approve care decisions they now routinely deny because they don’t want to pay for them.

The public option has been touted by some progressives as a stalking horse for single payer, and by the president as the vehicle to “discipline” the private insurers to compete fairly. But those insurers have well-developed means to cherry-pick healthy patients, leaving the sick to what is likely to be an underfunded public plan that, like many public systems in the US today, would soon face daunting choices of cutting access and services.

How brilliantly pragmatic the left has become, many willing to settle for a flawed reform and unwilling to challenge the fundamental right of corporations to control our health.

But not nurses. They see the reality of the insurance-based system clearly and experience it painfully. And, like many single-payer activists, they worry that the new bill will fail to meet the president’s own stated goals of universality, control of rising medical costs, and improving the quality of care — and so waste much of the goodwill and public trust his historic election has created.

By Leonard Rodberg
Worthington (Minn.) Daily Globe
July 11, 2009

NEW YORK — Underinsurance — the failure of insurance plans to protect us from the cost of needed medical care — is a growing problem for millions of middle- and lower-income Americans. As the national debate over reforming our costly and inefficient health care system heats up, recent studies show that deficiencies in our private insurance system afflict many more than the millions who are uninsured.

Yes, it’s true that the majority of Americans report they are satisfied with their insurance plans, and so politicians promise “you can keep what you have.” But what is it that we have? For growing numbers of Americans, our health insurance is completely inadequate.

Unfortunately, we don’t learn this until we actually get sick. Only when a serious illness or injury hits us do we find our plans really tested. Only then do we discover that co-payments, deductibles, exclusions, and denials leave us struggling to pay for our needed medical care.

We are told that our insurance will take care of us in time of need, but increasingly we are being sold a faulty product.

In a study of health insurance claims just published in the respected policy journal Health Affairs, researchers report that between 2003 and 2007 average out-of-pocket expenses paid by adults with employer-sponsored insurance grew by more than a third, to $729 per person each year. One in 10 adults faced out-of-pocket costs that averaged $3,364. This spending that insurance didn’t cover includes deductibles (which the patient must pay before insurance starts paying anything) and co-payments (the patient’s share of the remaining bill).

The study’s authors attributed the increase in costs to the overall rise in health care costs, along with a decline in the coverage provided by employer-sponsored insurance. In fact, the researchers concluded that “in the United States, if you are sick and earn a modest income, you are probably underinsured — even if you have employer-based coverage.”

In another study just published in the American Journal of Medicine, researchers from Harvard found that in 2007 illness and medical bills contributed to nearly two-thirds of all personal bankruptcies. This is a 50 percent increase from the number of similar bankruptcies found in 2001. The majority of medically bankrupt families were middle class and owned their homes. Most surprising, more than three-quarters of them were insured at the start of their illness.

These insured individuals and families were unable to pay out-of-pocket expenses that averaged $17,749. Severe illness caused many to lose their jobs, which in turn caused them to lose their coverage. The authors conclude that “the U.S. health care financing system is broken, and not only for the poor and uninsured. Middle-class families frequently collapse under the strain of a health care system that treats physical wounds, but often inflicts fiscal ones.”

As this research reveals, the way we pay for health care is not protecting us from heavy financial burdens, nor is it assuring us access to needed medical care. In spite of this, the health reform plans currently being considered in Congress would require that we purchase the very health insurance that is failing us. They do nothing to reduce the incidence of underinsurance; in fact, they spread it. They leave health insurance just the way it is now and would require even more people to buy it.

Advocates of a single-payer national health program point out that there is an alternative. With a public insurance program like Medicare, we could have comprehensive coverage of the care we need. We would also save hundreds of billions of dollars in wasteful administrative spending and contain costs going into the future. Such a plan, as embodied in Rep. John Conyers’ U.S. National Health Care Act (H.R. 676), would create a secure financing mechanism, eliminate the burden of out-of-pocket spending, and protect those of us who become ill from financial ruin.

As Rose Ann DeMoro, executive director of the California Nurses Association, has said, “The trouble for most families is not the lack of insurance, it’s the insurance they already have.” Unless we change how the country pays for health care, we won’t have the reform we really need.

Leonard Rodberg is professor and chair of Urban Studies at Queens College, City University of New York, and research director of the N.Y. Metro Chapter of Physicians for a National Health Program. www.pnhp.org.

http://www.dglobe.com/event/article/id/24864/

by Mike Hall
AFL-CIO Blog
Jul 10, 2009

Donna Smith, a community organizer and legislative representative for the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), was recently honored as the National Organization for Women’s (NOW’s) 2009 Woman of Action.

Smith first came to the public’s attention in Michael Moore’s 2007 movie, “SICKO.” Despite having health insurance and even a health savings account, Donna and her husband Larry were forced to move into their daughter’s basement after being unable to pay staggering health care costs–and were left in financial ruin.

Donna’s husband, Larry, suffered three heart attacks and Donna was diagnosed and treated for uterine cancer. There is even a scene in the movie “SICKO” where Michael Moore takes Donna to Cuba to get the necessary treatment their insurance wouldn’t pay for.

After the film was released, Smith became a health care activist, taking her story and those of other victims of the badly broken health care system around the country at rallies, teach-ins, seminars and demonstrations. She is a founder of the health care advocacy group American Patients United.

At the group’s recent national conference, NOW President Kim Gandy said Smith “epitomizes how to best confront the injustices in this world.”

Donna is speaking out, organizing, pressuring and advocating for solutions to fix the long-standing crisis produced by our unfair for-profit health care system.

Donna’s story is remarkable–from illness, bankruptcy, financial ruin–to fighting back and becoming an icon to millions as a health insurance reform advocate. We salute Donna for her hard work and tenacity.