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Single payer: bold, affordable, humane

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Single payer: bold, affordable, humane

[The following is the testimony of Dr. Walter Tsou to the House Subcommittee on Health, Employment, Labor and Pensions on June 10. The hearing was titled “Examining the single-payer health care option.”]

By Walter Tsou, M.D., M.P.H.

Congressman Andrews and members of the HELP subcommittee, my name is Dr. Walter Tsou. I am a public health physician and former Health Commissioner of Philadelphia.

If you believe that every American has the right to quality, affordable health care, then the only affordable means to achieve that goal is through a properly financed, single-payer national health insurance program.

Attempting to reconcile the dual imperatives of universal coverage and cost control through alternative methods besides single payer is an exercise in futility. It is clear that cost controls mean that someone’s ox gets gored, either the taxpayers’, physicians’ and hospitals’, or the private health insurance industry’s. When some Congressional leaders declare that “single payer is off the table,” they are, in effect, saying that insurers will be protected, leaving the pain to patients, taxpayers and health care providers.

Let’s examine each of these categories:

For the taxpayers, it is difficult to understand why we must endure an additional $1.5 trillion or more over the next decade in expenses at a time when our nation already spends 50 percent more per capita on health care than any other country in the world.

For physicians and hospitals, simply cutting reimbursements is counterproductive, especially at a time when we need to increase reimbursements for primary care and mental health services.

For the private insurance industry, they have dominated health care for the past 50 years, but it does not work. Despite a supposedly competitive marketplace, health care costs have skyrocketed, nearly 50 million are currently uninsured, and the quality of care for most Americans is “suboptimal,” in the words of the Agency for Healthcare Research and Quality. Choice is a total misnomer. Americans want to be able to choose their doctor and hospital, not their health plans.

A humane health care system should reinforce the safety net in the face of our nation’s worst recession since the Great Depression, but our profit-driven system kicks millions of Americans in the gut and leaves them both jobless and uninsured. We have saddled our nation with an inefficient and exorbitantly expensive health care system that drives jobs overseas where health benefit costs are low, and discourages entrepreneurs from striking out on their own for fear of losing their insurance coverage.

We need a far greater investment in community-based public health and preventive medicine, including home visitation for newborns and public health nurses doing chronic disease management in the community. But where will we get the funds?

Single payer is the only reform that can control health care costs. It does so by cutting insurance firms’ profits, streamlining the massive administrative apparatus that adds to the costs of hospital and doctors’ offices, using bulk purchasing, negotiating fee schedules with physicians, and putting hospitals on predictable, global budgets.

The $19 billion that has been set aside for health information technology is doomed to fail because it is dependent on a complex, fragmented health care financing system. In contrast, consider Taiwan, where everyone has a smart card. Your smart card carries your medical history and can be viewed by any doctor in Taiwan. Their national database allows them to identify the few outliers who try to abuse the system, rather than hassling millions of doctors and patients.

What the Internet has done to transform telecommunications across the world is what single payer will do to transform how we deliver health care in America. A national public health database would allow us to direct resources to areas of greatest need. We can change the incentives in reimbursement to advance our national health goals embodied in Healthy People 2020 and reward communities that help achieve those goals. This would encourage health professionals and hospitals to work together with local health departments to advance national health objectives.

President Obama has stated that if he were to start over again he would favor a single-payer system, but argues that moving to single payer is too radical.

Well, I come from Philadelphia where revolutionary ideas are celebrated not dismissed. Our most famous radical document begins with the words, “We the People,” not “We the Insurers.” “We the People of the United States, in order to form a more perfect union . . . to promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity do ordain and establish this Constitution for the United States of America.” This nation captured the world’s imagination with bold ideas that put the people first. It is time for our own generation’s revolution.

AMA and PNHP on public insurance

Doctors' Group Opposes Public Insurance Plan

By Robert Pear
The New York Times
June 10, 2009

As the health care debate heats up, the American Medical Association is letting Congress know that it will oppose creation of a government-sponsored insurance plan, which President Obama and many other Democrats see as an essential element of legislation to remake the health care system.

… in comments submitted to the Senate Finance Committee, the American Medical Association said: “The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans.”

The A.M.A., an umbrella group for 180 medical societies, does not speak for all doctors. One group, Physicians for a National Health Program, supports a single-payer system of insurance, in which a single public agency would pay for health services, but most care would still be delivered by private doctors and hospitals.

http://www.nytimes.com/2009/06/11/us/politics/11health.html?hp

Comment:

By Don McCanne, MD

In opposing a government-sponsored insurance plan, why would the AMA limit its objection to a public plan that would cover only non-disabled individuals under age 65? What about those over 65 and those with long-term disabilities? Of course, they are covered by Medicare, a plan that the AMA continues to lobby for, even though they were vehemently opposed to it before it was enacted.

We can only speculate as to why the AMA leadership would object to including everyone in an improved version of our very successful Medicare program. Some believe that the AMA House of Delegates is still dominated by right-wing reactionaries, as it was during the Medicare battles. A more likely explanation is that physicians, who are uniformly unhappy with both private and public insurance programs, may perceive a greater opportunity to bypass the third-party payers in the market of private sector plans that use high-deductibles, health savings accounts, and other payment innovations that would allow physicians to capture a greater portion of their often-unrealistic list fees.

Fortunately, many physicians believe that patients, all patients, are more important than wealth-creating opportunities. That’s what Physicians for a National Health Program is all about.

House HELP Committee hearing on single payer

Examining the Single Payer Health Care Option

Health, Employment, Labor, and Pensions Subcommittee Hearing
U.S. House of Representatives
June 10, 2009

Marcia Angell, M.D.:

I want to mention one final and very important reason for enacting a nonprofit single-payer health program. We live in a country that tolerates enormous and growing disparities in income, material possessions, and social privilege. That may be an inevitable consequence of a free market economy. But those disparities should not extend to denying some of our citizens certain essential services because of their income or social status.

One of those services is health care. Others are education, clean water and air, equal justice, and protection from crime, all of which we already acknowledge are public responsibilities. We need to acknowledge the same thing for health care. Providing these essential services to all Americans, regardless of who they are, marks a decent and cohesive society. It says that when it comes to vital needs, we are one nation, not 300 million individuals competing with one another.

***

Walter Tsou, M.D., M.P.H.:

President Obama has stated that if he were to start over again he would favor a single-payer system, but argues that moving to single-payer is too radical.

Well, I come from Philadelphia where revolutionary ideas are celebrated not dismissed. Our most famous radical document begins with the words, “We the People”. Not “We the Insurers”. “We the People of the United States, in order to form a more perfect union . . . to promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity do ordain and establish this Constitution for the United States of America.” This nation captured the world’s imagination with bold ideas that put the people first. It is time for our own generation’s revolution.

***

David Gratzer, M.D.:

Critics of the American system note that it fails to provide universal coverage to its citizens. But Canada’s single-payer system also denies care; instead of denying insurance coverage, Canada’s public insurance plans simply limit the supply of costly medications and capital-intensive procedures.

These challenges appear in different forms across the single-payer world. Wait times, rationed care and inefficient public management is inevitable in single-payer systems because they all face the same health-care demands as the American system.

***

During the questioning by committee members:

Rep. Dennis Kucinich: Dr. Gratzer, you’ve tried to make the case for rationing in Canada – worse than it is in the U.S. Do you know what Statistics Canada – the analogue to the U.S. Census – says the median wait time is across Canada for elective surgery?

Dr. David Gratzer: Why don’t you inform us,sir?

Kucinich: It’s four weeks. And what does Statistics Canada say the median wait time for diagnostic imaging like MRIs is?

Gratzer: I could tell you the Ontario government recently looked at that for…

Kucinich: It’s three weeks.

Gratzer: … for cancers, was six months.

Kucinich: It’s three weeks. How many uninsured are there in Canada?

Gratzer: Probably relatively few.

Kucinich: That’s right, none or very few. How many medical bankruptcies are there in Canada?

Gratzer: Depends on how you define medical bank..

Kucinich: None or very few. How many insured Americans go without needed care due to high cost of health care which is due to health insurance companies?

Gratzer: (Pause) Am I allowed to answer, or are we just going to continue to…

Kucinich: If you have an answer, you can answer. But if you don’t, I’ll answer. What’s your answer?

Gratzer: Go for it, sir.

Kucinich: What’s your answer?

Gratzer: Why don’t you answer your question, sir?

Kucinich: What’s your answer?

Gratzer: My answer…

Kucinich: How many insured Americans go without needed care due to the high cost of health care which is due to health insurance companies?

Gratzer: (Silence)

Kucinich: The witness isn’t responding.

Gratzer: The witness is delighted to speak further on those statistics and other statistics, but you keep cutting me off, sir.

Kucinich: You respond, if you have an answer. You didn’t give an answer to the other one.

Gratzer: I don’t want to be led down a garden path. If you’d like to ask me a question, I’d be…

Kucinich: You’ve shown a garden here to members of this committee and to the audience. There’s another side to this picture you don’t seem to be aware of even though you want to be an expert on Canada. Can you provide us with an answer on this one about America?

Gratzer: My position is respectable, and I dislike your comment, sir.

Kucinich: Do you have an answer? How many insured Americans, insured, go without needed care due to high costs of health care due to health insurance companies?

Gratzer: (Silence)

Kucinich: He has no answer. Well what the answer is is that it’s one out of every four. So we’re trying to make a case here that somehow Canada is in a mess, but we’re not focusing on the fact that in the United States there are people who aren’t getting needed care, and this gentleman has expected us to believe that rationing is worse in Canada. I don’t know how we can buy that. Now if single payer is so bad, maybe the gentleman – the doctor – can explain to us why sixty percent of U.S. doctors want it according to the peer-reviewed Annals of Internal Medicine, April, 2008.

(off camera voice): Are you going to let him answer this one?

Kucinich: He can answer it, if he can answer it.

Gratzer: I would suggest that many physicians in the United States are unsatisfied with their system, and rightly so. I would suggest that many physicians are looking for reform, and rightly so. But I would suggest that many physicians are unaware of what really goes on single payer systems, perhaps illustrated well by some of the comments that you’ve already made…

http://edlabor.house.gov/hearings/2009/06/examining-the-single-payer-hea.shtml

Comment:

By Don McCanne, MD

Although there are many individual heroes in the single payer movement, joint citizen activism has played a crucial role in bringing the single payer message to a formal, official hearing before a committee of the House of Representatives – a hearing devoted exclusively to single payer.

Tomorrow, Sen. Kennedy’s Health, Education, Labor, and Pensions committee will hold a hearing on “Healthcare Reform.” At the top of the list of the twenty-four witnesses is one of our heroes, PNHP’s Margaret Flowers, M.D., who previously had asked Sen. Baucus to bring single payer to the table, shortly before her arrest.

There are many effective channels for citizen activism. In whatever form you choose, let’s have a whole lot more of it please.

Expand state programs for low-income individuals?

State decides to let higher health-care premiums do dirty work

By Kyung M. Song
The Seattle Times
June 9, 2009

(Washington’s Basic Health Plan) has been open to any Washington resident who earns less than twice the poverty level.

Officials with Washington’s Basic Health Plan are resorting to steep premium increases to achieve what they were loath to do on their own — expel thousands of working-class people from the cash-strapped state insurance program.

Ending weeks of deliberations, officials announced Monday that Basic Health’s premiums will increase by an average of 70 percent on Jan. 1 as part of an ongoing strategy to boot 30,000 to 40,000 people off the taxpayer-subsidized plan, which covers roughly 100,000 members.

The bulk of the cuts will come from changes already under way. On top of that, officials are hoping that boosting premiums will prod 7,000 to 17,000 members to leave the plan on their own, sparing the state the need to kick off people involuntarily.

http://seattletimes.nwsource.com/html/localnews/2009316386_basichealth09m0.html

And…

Healthy Families Program

State of California
June 1, 2009

With the failure of the May 19th ballot Initiatives and the worsening budget situation, the Governor’s May Revision proposed limiting eligibility for the Healthy Families Program to those children with incomes at or below 200% FPL.

In addition, because of concerns about the ability to borrow funds, (Governor Schwarzenegger) directed the Department of Finance to develop additional budget reductions. One of the proposals is closing the Healthy Families Program. Both of these proposals will go through the Legislative budget process for review and consideration.

http://www.healthyfamilies.ca.gov/MyHealthyFamilies/HFP_Remains_Open_For_Enrollment.aspx

And…

Budget Conference Committee on SB 61

California State Assembly
Health
June 5, 2009

The Healthy Families Program (HFP) is California’s version of the federal Children’s Health Insurance Program (CHIP).

In this year’s initial May Revisions, the Governor proposed to reduce eligibility from 250 to 200 percent of the federal poverty level and to eliminate Certified Application Assistance. Subsequently, the Governor replaced these proposals with one proposal to fully eliminate the program.

http://www.senate.ca.gov/ftp/SEN/COMMITTEE/STANDING/BFR/_home/2009conf/6509CCHealth.pdf

Comment:

By Don McCanne, MD

Because of the very high costs of health care, the private insurers have not been able to offer products to low-income individuals that they can afford. In response, the federal and state governments have enacted programs designed to meet the health care needs of low-income individuals, usually financed jointly by the federal and state governments and administered by the states.

The current leading reform proposals would expand these programs to cover more of the low-income population. Is this a wise policy decision?

Most states have balanced budget requirements. Whenever spending exceeds revenues decisions must be made to either increase taxes or cut programs. Voters tend to penalize politicians who increase taxes. On the other hand, low-income individuals have a very weak political voice, and many of them do not even vote. Thus programs for the poor are a prime target for the budget cutting guillotine.

This background sets up the kind of thinking that is taking place at the state level.

The administrators of Washington’s Basic Health Plan are calling for individuals to voluntarily leave the program, and they are ensuring cooperation by raising premiums to levels that are unaffordable, thereby pricing them out of health care. Framing this as a voluntary decision of the beneficiaries rather than a budget-cutting decision of the administrators is blatantly dishonest and only compounds the nefariousness of their complicity.

At least California Governor Schwarzenegger is not hiding behind face-saving rhetoric. He proposes to flat-out throw a million children off of the state’s CHIP program, even though that would disqualify California from receiving generous federal subsidies.

Instead of fixing our health care financing system so that it provides everyone with affordable access to all necessary care, which we can easily do (improved Medicare for all), our leaders want to build on our uniquely American system. Surely other states can help with our budget problems by finding more children to join the ranks of the million uninsured California kids. That would be uniquely American. (I still can’t believe that they’ll go through with this, but the mere fact that it is under discussion shows how sick our health care financing system is.)

The Facts About the Health Insurance Industry

by Jeoffry B. Gordon, MD, MPH
DailyKos
Sun Jun 07, 2009

Most people are unaware how similar the major health insurers are to our failed Wall Street firms.They are corporate cash cows and have virtually no fiduciary responsibility and few activities for protecting or improving health or the health care system.They will devote their vast resources to prevent any meaningful health reform. They have controlled Congress and the mainstream media. The only cure is vigorous popular support for a single payer, Medicare for All reform.

This is a discussion about the huge and looming crisis in our nation’s health care system and the need for a radical paradigm changing reform. Because the issues discussed below necessarily involve a politically difficult restructuring of a large and well establish sector of our economy, the breadth and details of this reform have so far has been largely excluded from public policy discussions and debate. AHIP — American Health Insurance Plans — representing the private, for profit, health insurance companies and their partners had their annual national convention in San Diego, California this week. They are the association of all the major health insurers in the United States and their lobbying clout is unsurpassed. Major public political leaders of both parties, men like Jeb Bush, Dr. Howard Dean, and Tom Daschle attended.

As a practicing family physician who has been seeing patients since Medicare was started I can tell you what really ails our national health system. Making the correct diagnosis is important. Yet those in Washington — both in the White House and in Congress – both Republicans and Democrats — and the national media – are eagerly avoiding the right diagnosis and thus preventing public discussion about the necessary cures. As you all know if we don’t make the right diagnosis the disease will not be cured and the patient will not get better. Today the biggest barrier to improving our health care system in the United States is the private health insurance companies. They are the disease we suffer from. The best, and perhaps the only, public policy cure that will work is a single payer, Medicare for All, health care financing program. Yet due to financial power of the health insurance industry, their great financial lobbying clout, embarrassingly our elected officials are doing everything they can to avoid the current golden opportunity to create a single payer system.

I want to make only three main points:

1. The individual insurance companies are out for profit and must work to maximize their value on the stock market and not our friends. They treat patients like widgets or cost centers. This is not a culture of trust, caring, compassion, and fiduciary responsibility. If you were dumb enough to hope that Countrywide Mortgage would preserve your home and Lehman Brothers would preserve your retirement fund, then you will be stupid enough to expect Anthem Blue Cross and the other insurance companies to be there to protect your health. Yet it seems all Washington continues under this delusion.

2. The employer based private health insurance industry has been created by us, is hugely subsidized by public policy and public money and is expensive, inefficient, costly , and a structural barrier to a healthy America. It needs to be eliminated.

3. The only cure for our problem is a single payer, national, universal, health financing program like Medicare for All. This is not socialized medicine, but an efficient way to pool risk and share the unexpected costs of illness. Fifty percent of our population has virtually no medical expenses while five percent consume 25 percent of all personal medical care costs. This why we need the insurance principle: unexpected medical expenses are relatively rare and can be huge and should be spread across the whole population. Financial costs related to illness cause over 50 percent of personal bankruptcies in the United States. Over 46 million Americans are rationed out of the medical system (and during this economic catastrophe this number is growing by 10,000 people per day) 46 million people are subject to excess morbidity and mortality because they cannot afford financing and the insurance industry cannot profit from them. Health insurance is important and necessary. We need an efficient, national, publicaly sponsored, universal health financing system. This is the only treatment that will be a cure.

First, let me dwell on the track record of an individual insurance company, specifically United Health Plans. United Health Group is America’s largest health insurance company. According to their 2008 annual report United has 75,000 employees, insure 29.1 million Americans directly and cover up to 78 million people, contract with 650,000 doctors and 5200 hospitals. Their insurance programs include: a government subsidized Medicare Advantage program called Secure Horizons, a Medicare Part D prescription program called Prescription Solutions, and they have an exclusive arrangement with AARP to offer a Medicare supplement. The company has a subsidiary, Ingenix (remember this name) which provides “actuarial data, claims management services, and health intelligence” in 56 countries and in the USA to 6000 hospitals, 240,000 MDs, 1500 health plans, and 250 government agencies.
In 2008 United Health had total revenues of approximately $81.2 billion ($75.9 billion from health insurance and $1.6 billion from Ingenix) and their 2008 net revenue was $5.2 billion from health insurance. (This profit was in essence moneys diverted from health insurance premiums paid by government, individuals and employees to obtain medical care even after the company’s huge administrative costs are deducted.) They had an additional $229 million profit from Ingenix. According to SEC filings during our current economic and health care crisis their 2009 first quarter total revenue went up 8% to $22 billion and their net profit was $984 million. According to the company’s own report they have a medical loss ratio of about 80 per cent – that is, of collected premiums they spend only about 80 % on actual medical care, that is we loose 20 per cent of the money we pay them to their overhead and profit.

Some recent corporate history with you will demonstrate how far their corporate culture is from taking care of the sick and disabled. In 2006 The Wall Street Journal reported that company executives were back dating their stock options. Because of the ensuing scandal in October 15, 2006 company President and CEO William McGuire, who usually made between $60 and $120 million a year was forced to resign but he took with him the largest golden parachute ever paid, a compensation package estimated to be $1.1 billon. He was subsequently forced to pay back to the SEC $468 million in refunds and $7 million in penalties.In 2008 the net realized profit of the United HealthCare Group fell 36 per cent from 2007 — from $4.65 billion in 2007 to $2.98 billion in 2008 due to legal costs. In 2008, an investigation by New York State Attorney General Andrew M. Cuomo found that Ingenix and its parent UnitedHealth Group defrauded consumers and providers by manipulating its database used to quantify reasonable and customary medical care provider rates to make them remarkably lower than the actual cost of typical medical expense. This provided health insurance companies over the past 15 years the means to inappropriately lower payment of provider claims, thereby increasing the insurance companies’ profits and often leaving patients to pay the difference. The company paid a $50 million fine and set another $50 million aside to revamp its data system as an external organization under non-profit public supervision. In 2008 United Health paid another $895 million in legal and settlement costs in two other class action law suits, the major one brought by CALPERS retirement fund over the stock option deception. In addition, on January 15, 2009, UnitedHealth Group announced a $350 million settlement of three class action lawsuits filed in Federal court by the American Medical Association and others for not paying claims for out of network medical services to their patients. Anyone can easily see that the management of this company has no sense of public fiduciary responsibility and has focused major resources on making profit and manipulating the financing of health care. It is a real stretch to imagine that the same board of directors and top officials, so caught up in these huge illegal money grabs would really be interested in paying attention to my patients’, and your family’s, and our neighbors’ sickness and pain or in any remediation of our health care system’s problems.

In addition it is important to mention AARP — the AARP that supported the poorly designed Medicare Part D which became very profitable to insurance companies due to its mandated subsidies. The American Association of Retired People have an exclusive contract with this same United Health care to sell their health insurance policies. Do you know that AARP’s annual budget is over $1 billion a year and over $700 million of that comes from fees for selling insurance products. Some of these products are total rip offs as was recently revealed by our conservative Republican Senator from Iowa, Chuck Grassley who sent AARP a searing letter dated November 3, 2008. It embarrassed AARP and forced them to withdraw from the market several scandalous products (Essential Health Insurance Plan and Essential Plus Health Insurance Plan) developed by the United Health Group and sold by AARP to 44,000 people. You will note that AARP is always invited to the public policy table and the hearings to contribute to major political discussions about health care reform. This is totally inappropriate. AARP is part of the problem and not part of the solution. It is nothing but an insurance broker disguised as an advocacy group — and they will never take on the health insurance industry. AARP will represent the insurance industry rather than the public welfare in discussions about health reform.

Now examine the health insurance system as a whole: It should be obvious that the only functional purpose of the insurance company is to collect money (premiums) from one set of folks (people/patients) and pool it and then pay it to another set of folks (medical providers). Other than acting as a bank, there is NO value added. All the rest is expensive smoke and mirrors: marketing, false consumer choices, medical rating, care management — all of which they do poorly and very expensively. In fact, all these expensive activities are designed to either maximize profit or to be a window dressing rationale for their profit. Furthermore, the health insurance industry itself and its egregious expenses and profits are virtually wholly a creation of tax payer subsidy and 70 years of one sided industry supportive legislation. Federal programs such as Medicare, Medicaid, the Veteran’s Administration, Crippled Children’s Services, SCHIP, and the Ryan White Act take huge numbers of potentially expensive or chronically ill Americans out of the pool of privately insured people, allowing these private firms to cherry pick the most affordable enrollees.

Few people remember that the first private health insurance companies like the original Blue Cross and Blue Shield were not for profit entities with some charitable purpose. In 1944 FDR’s attorney general charged the South-Eastern Underwriters Association, an insurance company, with anti-trust price fixing. The case made it all the way to the Supreme Court, where the insurers made the audacious defense that they could not be regulated under the Interstate Commerce Clause of the Constitution because they were not a business, not “commerce.” The insurance company lost, but within a year their lobbyists took their revenge. In 1945 the McCarran-Ferguson Act declared that “No Act of Congress shall be construed to invalidate, impair, or supersede any law enacted by any State for regulating the business of insurance…” This why we are stuck with the relatively fragmented and impotent state attorney generals and 50 state agencies to regulate the massive corporate businesses represented by AHIP. (It takes a creative and powerful attorney general like Andrew Cuomo of New York to have an impact.) Since then and along the way the insurance lobby has had its way with state legislatures. First, the health insurance companies were allowed to give up community (a geographic standard) rating for medical rating (an individual disease history standard) — so they could increasingly exclude potentially expensive patients and secondly, not for profit health insurance companies were allowed to become for-profit so their companies and enrollees could be cheaply acquired by the expanding for-profit corporate giants like United Health care. In this process, over the last 65 years, the health insurance companies have long given up any semblance of being service organizations. They became the disease in our health care system. Now we have to deal with massive powerfully oligopolistic insurance companies. In February, 2009 the US GAO surveyed the small group health insurance market. They found “The five largest carriers in the small group market, when combined, (had)…three-quarters or more of the market in 34 of the 39 states…and they (had)…90 percent or more in 23 of these states.”

Each health provider has to deal with potentially 1500 different insurance companies, each with their own care rules and payment querks. In my office I regularly deal with about 40 payers. A study published just last month in HEALTH AFFAIRS, demonstrated that “billing and insurance-related functions” cost each FTE physician at least $85,276 a year (or about 10% of gross revenue) in time and staff. In the last 30 years the number of health system administrators has grown by 3000% while the number of physicians has grown 300%. In the past 9 years workers’ pay has grown 29% while the cost of health insurance net of administration has grown 75% and the net cost of health insurance administration has risen 106%. This year per capita health expenditures in the United States will approach $8000 a year or about 17 % of our GNP. A study by an international management consulting firm demonstrated that on an internationally adjusted comparative basis annual health care spending for each person in the United States is over $2000 a year more than would be econometrically appropriate given our nation’s wealth. This added expense is almost wholly due to the costs of the private, for profit health insurance system and adds no value. The bottom line is that the private, for profit health insurance companies divert on the order of $350 billion of insurance premium money from medical services. This is a sum which approaches the size of the peacetime Pentagon budget. Single payer reform will reallocate these moneys to care for the uninsured.

In order to understand why single payer reform has not been given a fair hearing in Washington I want to detail the power of AHIP. In 2008 alone they gave $36,695,680 to Congressional candidates – $17,493,170 to democrats and $19,128,523 to republicans. Senator Baucus, chairing the health reform hearings at the Senate Finance Committee, has raised $11.4 million from 2005 through now. Of this about $500,000 came from insurance companies, $500,000 from pharmaceutical companies, and $500,0000 from health professionals. This is why two weeks ago my concerned colleagues from the California Nurses Association and Physicians for A National Health Program had to disrupt the order of his hearings to point out he was ignoring the single payer reform option.

It is important to understand why a “public health insurance plan” created to “stand beside” existing private health insurance plans does not provide a cure. This proposal is based in part on the experience in Massachusetts. The current Massachusetts universal coverage health reform plan is being looked upon as a model for the nation. It has had some success, yet it cannot and must not be used as a model for national reform with a “stand along public health plan” option. The Massachusetts model relies on government subsidy directed through the private health insurance carriers. There are three important observations here:

1. A 2007 study sponsored by AHIP reviewed prior experience with this type of reform model in 8 states in the 1990s (Kentucky, Maine, Massachusetts (in 1996), New Hampshire, New Jersey, Vermont, and Washington). They found that “in general…, individual health insurance markets deteriorated….Often, insurance companies chose to stop selling individual insurance in the market….Enrollment in individual insurance also tended to decrease, and premium rates tended to increase, sometimes dramatically…(And) we did not observe any significant decreases in the level of uninsured persons following the enactment of these market reforms.” The result was that all these reform programs failed and went out of existence.

2. Even with state government subsidy and leverage on premium charges many residents are excused from the “universal” program because they cannot afford the premiums. Many others are faced with unacceptably high and unaffordable copayments, deductibles, and benefit limits built into the approved insurance plans.

3. The program is totally dependent on the private insurance companies and there is no cost and minimal quality control mechanisms built in. The state of Massachusetts is thus currently facing a huge and perhaps intolerable budgetary deficit.

Finally, the cure is conceptually simple, but admittedly politically difficult. If the disease is an expensive and dysfunctional private, for profit health insurance system, the only possible cure is a single payer, Medicare for All reform. This option must not only be on the table, but must be passed into law. Our elected representatives must be supported to have the courage to objectively evaluate its benefits, and then given the backbone to pass it. This option already exists in the detailed legislative form contained in HR 676 by Congressman Conyers and already endorsed by 70 Congressmen and women. It contains five simple to understand solution components:

1. AUTOMATIC ENROLLMENT — Everyone receives a card assuring payment for all needed care by any willing licensed provider. This would eliminate the need for expensive marketing and sales campaigns and the broker system. Universal coverage will also shrink the need for workman’s compensation insurance as well as medical malpractice insurance.

2. FREE CHOICE OF DOCTOR AND HOSPITAL

3. DOCTORS AND HOSPITALS REMAIN INDEPENDENT and negotiate fees and budgets with public agencies. This is not socialized medicine.

4. A PUBLIC AGENCY PROCESSES AND PAYS ALL BILLS. This should massively cut the administrative overhead drain generated both by insurance companies, by employer HR departments, and by medical providers from the order of 40 % of costs to 10% of costs allowing an estimated savings of $50 billion in the first year and up to $250 billion annually which can be used to cover the currently uninsured without the need to add new taxpayer subsidy. Money is provided by this law to retrain displaced insurance company workers.

5. The system would be FINANCED BY PROGRESSIVE TAXES. This would lift the burden of health insurance costs from America’s businesses making them more internationally competitive; widely expand the risk poll, thus lowering the cost for every individual participant, and eliminate the need for expensive HR systems.

The information, discussion, and perspective presented here has been virtually absent from White House, Congressional, and media discussions of the need to reform the health care system. This seems to be largely because of the political and financial clout of AHIP. It is important to know that single payer reform, Medicare for All, is the only proposal in the public arena with broad, enthusiastic support from the men and women on the street who must understand these facts to be motivated to get involved.

Hold out for single payer

By Nick Skala

The following remarks were presented to the Congressional Progressive Caucus on June 4.

Today the Congressional Progressive Caucus faces a choice. That choice is whether Members should maintain their unflinching support for single-payer, or to accede to intense political pressure to support the plan currently being developed in Congress under the direction of President Obama: a mandate for Americans to purchase an insurance plan from a massive new regulatory “exchange,” with one plan potentially being a “public option.”

The difference between these choices could not be more stark: single-payer has at its core the elimination of U.S.-style private insurance, using huge administrative savings and inherent cost control mechanisms to provide comprehensive, sustainable universal coverage.

The “public option” preserves all of the systemic defects inherent in reliance on a patchwork of private insurance companies to finance health care, a system which has been a miserable failure both in providing health coverage and controlling costs.

Elimination of U.S.-style private insurance has been a prerequisite to the achievement of universal health care in every other industrialized country in the world. In contrast, public program expansions coupled with mandates have failed everywhere they’ve been tried, both domestically and internationally.

Many progressives accept that the “public option” is inferior to a single-payer system, yet support it because of its perceived political expedience. It is my aim today to convince you that the “public option” program currently being developed is not only bad health policy, but bad health politics.

On two separate occasions last month, physicians and nurses were dragged from the Senate Finance Committee in handcuffs for demanding that single-payer be considered in our nation’s health reform debate. These were American doctors and nurses, people who care for patients, people who want to practice medicine, not protest and disrupt Congress.

But these professionals risked their careers and their freedom. They did this not because they thought that the “public option” was “good” and single-payer “better.” They did it because they are firmly convinced, by well-established health policy science, that the so-called “public option” has no hope of remedying the systemic defects that cause their patients to suffer and die, sometimes before their very eyes.

Millions of dollars have been spent by political advocacy groups to commission polls and statistics “proving” that their health reform is “politically feasible.” Yet political winds do not make good health policy. Careful examination of science and experience do. And it is in the science and experience that we see that single-payer offers the only way to truly comprehensive, universal and sustainable health care, and that “public option” schemes offer only more of the same: tens of millions of uninsured, rapidly deteriorating coverage, an epidemic of medical bankruptcy, and skyrocketing costs that will eventually cripple the system.

First, because the “public option” is built around the retention of private insurance companies, it is unable – in contrast to single-payer – to recapture the $400 billion in administrative waste that private insurers currently generate in their drive to fight claims, issue denials and screen out the sick. A single-payer system would redirect these huge savings back into the system, requiring no net increase in health spending.

In contrast, the “public option” will require huge new sources of revenue, currently estimated at around $1 trillion over the next decade. Rather than cutting this bloat, the public option adds yet another layer of useless and complicated bureaucracy in the form of an “exchange,” which serves no useful function other than to police and broker private insurance companies.

Second, because the “public option” fails to contain the cost control mechanism inherent in single-payer, such as global budgeting, bulk purchasing and planned capital expenditures, any gains in coverage will quickly be erased as costs skyrocket and government is forced to choose between raising revenue and cutting benefits.

Third, because of this inability to control costs or realize administrative savings, the coverage and benefits that can be offered will be of the same type currently offered by private carriers, which cause millions of insured Americans to go without needed care due to costs and have led to an epidemic of medical bankruptcies.

Supporters of incremental reform once again promise us universal coverage without structural reform, but we’ve heard this promise dozens of times before.

Virtually all of the reforms being floated by President Obama and other centrist Democrats have been tried, and have failed repeatedly. Plans that combined mandates to purchase coverage with Medicaid expansions fell apart in Massachusetts (1988), Oregon (1992), and Washington state (1993); the latest iteration (Massachusetts, 2006) is already stumbling, with uninsurance again rising and costs soaring. Tennessee’s experiment with a massive Medicaid expansion and a public plan option worked – for one year, until rising costs sank it.

The Federal Employee Health Benefit Program (the model for a health insurance exchange) leaves hundreds of thousands of federal workers uninsured, and has proven unable to contain costs.

Negative results in a recent series of randomized trials explodes the hope that chronic disease management will cut costs. And the CBO has thrown a wet blanket on the notion that electronic medical records save money.

As Drs. David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, have remarked, a public plan option does not lead toward single-payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan. A quarter-century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry-picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan – which started as a single-payer system for seniors and have now become a funding mechanism for HMOs – and a place to dump the unprofitably ill.

Progressive supporters of the “public option” readily concede that single-payer is a superior system. Indeed, their response to evidence that their plan won’t work is to commission more charts and graphs emphasizing its political feasibility.

The “public option” is truly the embodiment of health policy designed by sound bytes, cobbled together from snippets of information gathered from focus groups and public opinion polls, and centered around well-polling buzzwords such as “choice” and “shared responsibility.”

Such a plan may be enough to excite the political classes in Washington, who care more about what they think can pass the Congress than what will actually deliver universal, comprehensive health care for all. But doctors and nurses, the people who actually work in the health system, see right through it. They are going to jail because they know that this plan won’t work for their patients.

Nobody is going to jail for the “public option,” because the American people cannot be inspired by band-aids and half-measures it is impossible to believe in.

These doctors and nurses are the manifestation of a social movement, millions strong, that is waiting to be mobilized by the leadership of the Members in this room. Polls consistently show that two-thirds of the American people want single-payer. At a recent hearing in Montana convened by Sen. Max Baucus, only 10 people of three hundred said they were happy with the insurance they have. Sixty percent of physicians support single-payer, as do the U.S. Conference of Mayors and 39 state labor federations and hundreds of local unions across the country.

We’re told that holding out for single-payer is politically unwise, but to compromise and accept a bad plan at precisely the time when popular support and grassroots energy are on the side of true reform is the real political miscalculation.

The history of great social achievement is rife with instances in which the forces of institutionalized power told social movements – as they now tell this one – that what they wanted was too much, or too fast, or too soon. I think, of course, of the abolition of human slavery, the enfranchisement of women, the Civil Rights Movement, Social Security, the minimum wage, an end to child labor. In each of these instances, social movements held fast to their principles and soon discovered that they had been told was “politically unfeasible” one moment was political reality the next.

We currently have a better chance to pass single-payer than Lyndon Johnson had when he passed Medicare. Unlike the public option, single-payer – because it holds the potential to finally realize universal, equitable health care – can be a vehicle to inspire the American people for progressive change.

The voices of doctors and nurses can achieve extraordinary resonance when they speak selflessly in their patients’ interest. But your leadership is crucial to inspire the American people. It is my hope that you’ll see fit to provide it.

Click here for a printable version of the handout below.

The “Public Option” Fails as Health Politics:

  Single-Payer “Public Option”
Number Insured Universal Coverage Millions remain uninsured or underinsured
Coverage Coverage for all medically necessary services. Insurers continue to strip-down policies and increase patients’ co-payments and deductibles.
Cost Redirect $350 billion in administrative waste to care; no net increase in health spending. Increase health spending more than $1 trillion over 10 years.
Savings $350 billion in administrative waste. Further systemic savings achieved through negotiated fee schedule with physicians, global budgeting of hospitals, bulk purchasing of pharmaceuticals, rational planning of capital expenditures, etc. Add further layers of administrative bloat to our health system through the introduction of a regulator / broker “exchange.”
Sustainability Large scale cost controls (global budgeting, capital planning, etc.) ensure that benefits are sustainable over the long term. Uncontrolled costs ensure that any gains in coverage are quickly erased as government is forced to hike spending or slash benefits.

But Getting “Something” is Better than Getting “Nothing,” Isn’t It?

Not if that “something” makes it more difficult to reach a real solution and ensures temporary relief will be followed by prolonged suffering. The “public option” may allow some people to buy inadequate insurance products for a short time. But such a system will quickly be crushed by the weight of rising health care costs, as Medicaid, SCHIP and dozens of state initiatives have been.

In addition, expending political capital on reforms that we know will fail makes the public cynical and gives ammunition to those who say that the government cannot create effective programs. Hence, any attempt at real reform is delayed, usually by decades. The minor temporal relief that reformers might get by acquiescing to insurance industry demands is simply not worth the continued suffering of the American people.

But Such a System to Could be a “Step” Towards Universal Coverage, Right?

No. Enacting phony “universal coverage” has not brought any state closer to a single-payer system. Since the early 1990s, Minnesota, Oregon, Maine, Florida, Utah, Washington, California, Vermont and Massachusetts have been among the states that have attempted to “patch-up” their fundamentally fl awed systems while retaining a place for insurance companies. All have failed. Upon passage, incremental reforms in each of these states were hailed by politicians and the media as a “step toward universal coverage.” Yet despite all the claims of pragmatism, incremental reformers have been unable to shepherd through meaningful change in nearly four decades of trying. And while reformers in these states continue to wait for the next “step,” residents continue to suffer.

The definition of insanity is to repeat an action expecting a different result. This is exactly what we have done in continuing to advocate incremental reforms as “steps” toward single-payer. What Americans need is not more proposals for patchwork reforms. We need leaders willing to stand up for the only solution that will work.

Nick Skala is a member of Physicians for a National Health Program (www.pnhp.org).

Protesters want Baucus to consider single-payer system

By JOHN S. ADAMS
Great Falls Tribune
June 6, 2009

HELENA–Undeterred by Sen. Max Baucus’ steadfast refusal to inject single-payer into the congressional debate on health care reform, more than 100 proponents of a “Medicare-for-all” form of nationalized health insurance rallied for their cause on Friday.

Protesters in Helena, Great Falls, Missoula, Bozeman and Butte gathered at Baucus’ local field offices and demanded that Montana’s senior senator, and chairman of the powerful Senate Finance Committee, put single-payer back on the table.

Eric Feaver, president of the state’s largest labor union, MEA-MFT, addressed the crowd at the amphitheater at the Great Northern Town Center and said he doesn’t want to “trash” Baucus, but that Baucus is on the wrong path by ignoring single-payer.

“I think he has a very difficult job and he has 100 senators to work with that are not of one mind,” Feaver said. “But I am here to remind Sen. Baucus that MEA-MFT does have 18,000 members who live and work everywhere in this state and they all vote. And they have supported single-payer for many years.”

Though Baucus has been frigid to the idea of single-payer, he has said he’d consider supporting a public option in which the federal government would create an insurance plan that would compete with private insurance plans. However, Baucus also has floated the idea of taxing employer-provided health care benefits, a proposal MEA-MFT adamantly opposes, Feaver said.

“The working men and women of this state support health care reform, and they want the most comprehensive health care reform possible,” Feaver said.

Kim Abbott, lead organizer for the Montana Human Rights Network’s Right to Healthcare program, said affordable health care is not a privilege, but a human right.

“There is nothing more infuriating, or frustrating or sickening than knowing the answer but not having the political will to do the right thing,” Abbott said. “We all know the answer. What’s the answer?”

“Single payer!” the crowd responded.

Dr. Carol Paris, a Maryland psychiatrist who was twice arrested last month for protesting single-payer’s exclusion from two Senate Finance Committee hearings, also appeared at Friday’s rally.

Paris, who was introduced as a “hero” of the single-payer movement for her acts of civil disobedience, said single-payer advocates need to “keep the heat on Sen. Baucus.”

“The next 60 days truly are critical,” Paris said. “We need to keep the momentum going here and in Washington.”

Paris said single-payer advocates have three demands of Baucus.

* That he and Sen. Ted Kennedy, D-Mass., hold Senate hearings on the merits of single-payer health care.

* That Baucus order the Congressional Budget Office to study the costs of implementing the Senate and House versions of single payer bills that have already been introduced.

* That Baucus arrange a meeting between President Barack Obama and single-payer experts.

After the rally protesters walked to Baucus’ office around the corner. A Baucus staffer handed protesters a sheet of paper with Baucus’ position on single payer.

“For more than a year Sen. Baucus has been laying the ground work to enact comprehensive, meaningful health care reform,” the letter said in part.

It went on to say that Baucus and single-payer advocates “share the same goal.”

“Both Senator Baucus and single payer advocates believe that every Montanan should have quality, affordable health care,” the letter stated.

The two sides remain far from agreement on how to achieve that goal.

Kaiser Health Tracking Poll

Kaiser Health Tracking Poll

Kaiser Family Foundation
April 2-8, 2009

7. Now I’m going to read you some different ways to increase the number of Americans covered by health insurance. As I read each one, please tell me whether you would favor it or oppose it. Here’s the (first/next) one — (INSERT AND RANDOMIZE- ALWAYS ASK ITEMS d AND h LAST). Do you favor or oppose this? (Is that strongly favor/oppose or somewhat favor/oppose?)

Items b-d based on half sample (n=616)
Items e-h based on half sample (n=587)

a. Requiring employers to offer health insurance to their workers or pay money into a government fund that will pay to cover those without insurance
71% favor
25% oppose

b. Offering tax credits to help people buy private health insurance
67% favor
29% oppose

c. Expanding Medicare to cover people between the ages of 55 and 64 who do not have health
insurance
79% favor
18% oppose

d. Creating a government-administered public health insurance option similar to Medicare to compete with private health insurance plans
67% favor
29% oppose

e. Expanding state government programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program
77% favor
20% oppose

f. Requiring all Americans to have health insurance, either from their employer or from another source, with financial help for those who can’t afford it
72% favor
25% oppose

g. Having a national health plan in which all Americans would get their insurance from a single government plan
49% favor
47% oppose

h. Creating a public health insurance option similar to Medicare to compete with private health insurance plans
67% favor
29% oppose

http://www.kff.org/kaiserpolls/upload/7892.pdf

Comment:

By Don McCanne, MD

Two-thirds to three-fourths of Americans support each of the reform options listed, except one. Americans are fairly evenly divided on “Having a national health plan in which all Americans would get their insurance from a single government plan.”

This is not a fluke. When the same survey was conducted in December, 2008 (minus the questions on public health insurance options), the results were very similar.

We could speculate as to why this poll seems to indicate less support for a single payer national health program than do other polls. Factors such as phrasing, context, demographics of the population polled, and so forth could explain the variation in the responses. If so, that would suggest that single payer support is quite malleable. That would mean that the threshold of a mandate for single payer reform has not yet been reached.

My opinion, which some may dispute, is that healthy Americans, who have good jobs and what they perceive to be adequate, employer-financed health care coverage, are not yet ready to trade that insurance in for an unknown government program which they assume they would have to pay for themselves, either through a premium or through higher taxes.

Pretending that the majority of Americans would risk their current health security for a more egalitarian system for everyone will not move the process for reform forward. Only when people understand that a single payer system would benefit them individually would they be willing to support reform that incidentally benefits everyone else as well.

We still have work to do.

Concerns about conflict of interests apply to Grassley, too

By JESS FIEDOROWICZ
Des Moines Register
June 7, 2009

Over the last several years, Iowa Sen. Charles Grassley has aggressively campaigned against conflict of interests in academic medicine. He has criticized academics at dozens of institutions across the country, including but not limited to Harvard and Stanford universities. His primary targets are government-funded researchers who had undisclosed or inadequately disclosed ties to the pharmaceutical industry. The concern as detailed by Grassley in a letter to the chancellor of the University of Texas system is that “funding from pharmaceutical companies can influence scientific studies, continuing medical education, and the prescribing patterns of doctors.” Beyond disclosure of this conflict, Grassley demands an explanation of how “the interest has been managed, reduced, or eliminated.”

The disclosure and management of conflict of interests is indeed an important concern for those with an ethical and fiduciary responsibility to act in the best interests of others. Physicians have a responsibility to act in the best interests of their patients. Elected officials have a responsibility to act in the best interests of those they represent. We should be pleased Grassley has brought up this very timely, relevant issue.

The Senate Finance Committee, on which Grassley serves as the ranking member, has recently taken up the issue of health-care reform. While potential conflicts of interest for committee members have not been formally disclosed as part of the process, the data is publicly available. According to MAPLight.org, Grassley received $376,893 and $243,722 in campaign contributions from the insurance and pharmaceutical industries, respectively, from 2003-2008. During this time, Committee Chairman Sen. Max Baucus (D-Mont.) received $592,185 and $524,813, from the same respective industries. There does not appear to be any plan to reduce or eliminate these apparent conflicts of interests. Yet, any conflict may interfere with the ethical and fiduciary responsibility of our representatives, and the behavior of committee members suggests conflicting interests.

In several polls, the majority of Americans and physicians support national health insurance. A single-payer, national health-insurance system could save over $350 billion annually by reducing unnecessary overhead and bureaucracy and is the most affordable option to provide universal coverage. Advocates for single-payer, national health insurance, however, were denied a seat at the table in Senate Finance Committee hearings led by Baucus, who instead included industry “stakeholders.” Grassley has gone even further, opposing any public plan, arguing “that the government is an unfair competitor” to private insurers. The position of the private insurance industry appears to be well represented. Populist proposals such as single payer have been ignored in the setting of strong industry opposition.

Money and power have tremendous influence in Washington. Grassley’s crusade against conflict of interests in academic medicine may provide insight into how we can combat similar undue influence in Washington to protect our democracy. Our representatives need to not only disclose conflicts, but also take measures to reduce risk. This minimally requires open inclusion and serious consideration of proposals with proven effectiveness or popular support, such as single-payer, national health insurance. It further requires re-identification of the American public as the real “stakeholders.”

JESS FIEDOROWICZ is an academic psychiatrist. Contact: mkejess@yahoo.com

Doctor critical of Baucus promotes single-payer plan

By MIKE DENNISON
Billings Gazette
Saturday, June 06, 2009

HELENA – Maryland psychiatrist Carol Paris is calling herself one of the “Baucus 13” these days – in other words, one of the 13 doctors, nurses and activists arrested last month while protesting before a Washington, D.C., health reform hearing chaired by Sen. Max Baucus, D-Mont.

On Friday, Paris was in Montana, doing what got her arrested: urging Baucus, Congress and the president to consider a single-payer system of national health insurance that covers all citizens equally.

“The next 60 days are critical,” she told a rally of 150 single-payer supporters in Helena. “We need to keep the heat on Sen. Baucus (and Congress and the president).”

Single-payer advocates held rallies in six Montana cities on Friday.
Paris, 56, is a member of Physicians for a National Health Program, whose 16,000 members are pushing for a national, publicly funded insurance plan that would replace private health insurance. The group paid for her trip to Montana.

In an interview Friday with the Gazette State Bureau, Paris said she used to believe that the private health insurance market could be reformed to improve health care, and she spent several years lobbying the Maryland Legislature.

“After a few years, I came to the conclusion that it was just a phenomenal waste of time,” she said. “At that point, I just said, there has to be a better place for me to put my time and energy.”

That was just six months ago, when she joined PNHP, to push for a single-payer system.

But Paris and other Maryland-area members found themselves basically ignored by Congress. They planned to protest – and get arrested – at a Senate Finance Committee hearing on health reform, chaired by Baucus.

Paris and her colleagues showed up the morning of May 5, spread themselves among the gallery and, one by one, interrupted Baucus as he started the meeting.

“I interrupt this so-called public hearing to bring you the following unpaid political announcement: Put single-payer on the table,” Paris said before she was arrested. “My name is Dr. Carol Paris, and I approved this message.”

Capitol police arrested the protesters, who have been charged with disrupting Congress.

Baucus, a key senator in drafting health reform legislation, said last week that he’ll ask that the charges be dropped. He’s said repeatedly that a single-payer system won’t be considered as a reform and is backing changes that maintain private health insurance.

Baucus spokesman Ty Matsdorf said Friday that the senator and single-payer advocates have the same goal of providing “quality, affordable health care to every American,” and that Baucus is confident that Congress will pass meaningful reform to “make this goal a reality.”

Paris, however, said her experience in private practice has convinced her that true reform can happen only if private health insurance is replaced with national, public insurance for all.

No longer would physicians’ staff have to spend hours dealing with multiple insurers on billing, no longer would patients have to do the same, and no longer would patients have to worry about which doctor is “in network,” she said. “You can go to any doctor you want,” Paris said. “It’s the private insurance industry where you can’t go to any place you want.”

Paris’s arrest was covered prominently by her local newspaper but received little or no attention from national news outlets.

She said she’s not surprised: “The mainstream, national media have blacked us out as much as Congress has. … I would say they’re following the lead of the president and Congress and simply not giving us a voice.”

Yet Paris said the reaction from her patients, as well as many fellow physicians, has been overwhelmingly positive.

She said she hears “over and over and over again” how people are frustrated by the current system, particularly dealing with their insurer, and that as soon as they understand how single-payer would work, they usually support it.

“I think that the only thing that keeps this from happening is the lack of political will by the president and our Congress,” Paris said.

Debunking Canadian health care myths

By Rhonda Hackett
The Denver Post, June 7, 2009

As a Canadian living in the United States for the past 17 years, I am frequently asked by Americans and Canadians alike to declare one health care system as the better one.

Often I’ll avoid answering, regardless of the questioner’s nationality. To choose one or the other system usually translates into a heated discussion of each one’s merits, pitfalls, and an intense recitation of commonly cited statistical comparisons of the two systems.

Because if the only way we compared the two systems was with statistics, there is a clear victor. It is becoming increasingly more difficult to dispute the fact that Canada spends less money on health care to get better outcomes.

Yet, the debate rages on. Indeed, it has reached a fever pitch since President Barack Obama took office, with Americans either dreading or hoping for the dawn of a single-payer health care system. Opponents of such a system cite Canada as the best example of what not to do, while proponents laud that very same Canadian system as the answer to all of America’s health care problems. Frankly, both sides often get things wrong when trotting out Canada to further their respective arguments.

As America comes to grips with the reality that changes are desperately needed within its health care infrastructure, it might prove useful to first debunk some myths about the Canadian system.

Myth: Taxes in Canada are extremely high, mostly because of national health care.

In actuality, taxes are nearly equal on both sides of the border. Overall, Canada’s taxes are slightly higher than those in the U.S. However, Canadians are afforded many benefits for their tax dollars, even beyond health care (e.g., tax credits, family allowance, cheaper higher education), so the end result is a wash. At the end of the day, the average after-tax income of Canadian workers is equal to about 82 percent of their gross pay. In the U.S., that average is 81.9 percent.

Myth: Canada’s health care system is a cumbersome bureaucracy.

The U.S. has the most bureaucratic health care system in the world. More than 31 percent of every dollar spent on health care in the U.S. goes to paperwork, overhead, CEO salaries, profits, etc. The provincial single-payer system in Canada operates with just a 1 percent overhead. Think about it. It is not necessary to spend a huge amount of money to decide who gets care and who doesn’t when everybody is covered.

Myth: The Canadian system is significantly more expensive than that of the U.S.

Ten percent of Canada’s GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada’s. Part of the reason for this is uninsured and underinsured people in the U.S. still get sick and eventually seek care. People who cannot afford care wait until advanced stages of an illness to see a doctor and then do so through emergency rooms, which cost considerably more than primary care services.

What the American taxpayer may not realize is that such care costs about $45 billion per year, and someone has to pay it. This is why insurance premiums increase every year for insured patients while co-pays and deductibles also rise rapidly.

Myth: Canada’s government decides who gets health care and when they get it.

While HMOs and other private medical insurers in the U.S. do indeed make such decisions, the only people in Canada to do so are physicians. In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be.

There are no requirements for pre-authorization whatsoever. If your family doctor says you need an MRI, you get one. In the U.S., if an insurance administrator says you are not getting an MRI, you don’t get one no matter what your doctor thinks — unless, of course, you have the money to cover the cost.

Myth: There are long waits for care, which compromise access to care.

There are no waits for urgent or primary care in Canada. There are reasonable waits for most specialists’ care, and much longer waits for elective surgery. Yes, there are those instances where a patient can wait up to a month for radiation therapy for breast cancer or prostate cancer, for example. However, the wait has nothing to do with money per se, but everything to do with the lack of radiation therapists. Despite such waits, however, it is noteworthy that Canada boasts lower incident and mortality rates than the U.S. for all cancers combined, according to the U.S. Cancer Statistics Working Group and the Canadian Cancer Society. Moreover, fewer Canadians (11.3 percent) than Americans (14.4 percent) admit unmet health care needs.

Myth: Canadians are paying out of pocket to come to the U.S. for medical care.

Most patients who come from Canada to the U.S. for health care are those whose costs are covered by the Canadian governments. If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise), the provincial government where you live fully funds your care. Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is.

Myth: Canada is a socialized health care system in which the government runs hospitals and where doctors work for the government.

Princeton University health economist Uwe Reinhardt says single-payer systems are not “socialized medicine” but “social insurance” systems because doctors work in the private sector while their pay comes from a public source. Most physicians in Canada are self-employed. They are not employees of the government nor are they accountable to the government. Doctors are accountable to their patients only. More than 90 percent of physicians in Canada are paid on a fee-for-service basis. Claims are submitted to a single provincial health care plan for reimbursement, whereas in the U.S., claims are submitted to a multitude of insurance providers. Moreover, Canadian hospitals are controlled by private boards and/or regional health authorities rather than being part of or run by the government.

Myth: There aren’t enough doctors in Canada.

From a purely statistical standpoint, there are enough physicians in Canada to meet the health care needs of its people. But most doctors practice in large urban areas, leaving rural areas with bona fide shortages. This situation is no different than that being experienced in the U.S. Simply training and employing more doctors is not likely to have any significant impact on this specific problem. Whatever issues there are with having an adequate number of doctors in any one geographical area, they have nothing to do with the single-payer system.

And these are just some of the myths about the Canadian health care system. While emulating the Canadian system will likely not fix U.S. health care, it probably isn’t the big bad “socialist” bogeyman it has been made out to be.

It is not a perfect system, but it has its merits. For people like my 55-year-old Aunt Betty, who has been waiting for 14 months for knee-replacement surgery due to a long history of arthritis, it is the superior system. Her $35,000-plus surgery is finally scheduled for next month. She has been in pain, and her quality of life has been compromised. However, there is a li
ght at the end of the tunnel. Aunt Betty — who lives on a fixed income and could never afford private health insurance, much less the cost of the surgery and requisite follow-up care — will soon sport a new, high-tech knee. Waiting 14 months for the procedure is easy when the alternative is living in pain for the rest of your life.

Rhonda Hackett of Castle Rock is a clinical psychologist.

http://www.denverpost.com/opinion/ci_12523427

Q&A with: Single-payer advocate Dr. Thomas Clairmont

By Michael McCord
New Hampshire Business Review
Friday, June 5, 2009

Portsmouth physician Thomas Clairmont — who has practiced medicine since 1977 and is a vocal member of Physicians for a National Health Program — considers the current health reform effort a dog-and-pony show.

As he watches the health-care reform debate in Washington — mostly with frustrated amusement — Dr. Thomas Clairmont, a primary care physician in Portsmouth, can offer his own diagnosis and prescription for what ails health care in this country in five minutes or less.

Clairmont, who has practiced medicine since 1977 and is a vocal member of Physicians for a National Health Program, considers the reform effort in Congress a dog-and-pony show produced by the health-care industry for public consumption.

“We aren’t having a debate right now. We’ve seen it before, and this usually leads to nothing significant happening,” said Clairmont, who advocates a government-run, single-payer solution — one that a bipartisan majority of politicians and President Obama are ignoring as best they can, he contends.

“Who is Senator (Max) Baucus (chair of the Senate Finance Committee, which is shepherding health-care legislation through the Senate) and how is that he will determine what kind of reform we will have?”

In May, a few PNHP doctors were arrested at a Senate hearing chaired by Baucus after they protested the exclusion of single-payer advocates from testifying. Clairmont said the Obama administration attempted a similar snub at its national health-care forum in March when it originally invited no single-payer supporters — even Rep. John Conyers, D-Mich., who has introduced single-payer legislation in Congress.

“I’m not a radical. I like taxes low and limited government spending, but health care should be a right and not a privilege,” Clairmont said. “We are hearing talk about reform and fears about socialized medicine or single-payer being politically unfeasible — but our plan is simple and it will save money because it focuses on health care and not making money for the insurance industry. And we are frustrated because it’s not being taken seriously.”

What’s at stake in health-care reform is a battle over money and how it will be allocated. According to the Centers for Medicare and Medicaid Services, health-care costs will total $2.5 trillion in 2009, or about 15.5 percent of the country’s gross domestic product. Health-care spending per person is estimated at $8,100 per person — while more than 47 million Americans have no health insurance, a statistic determined before the recession.

Clairmont concedes the fight isn’t easy but he says it’s necessary because if the latest reform effort plays out as he believes it will, they will be back to square one within the next three to five years.

Q. How long have you been a single-payer advocate?

A. In 1994, I attended the New Hampshire Medical Society meeting in which the then-AMA president from Maine debated Dr. David Himmelstein, the founder of PNHP. It wasn’t even close, as the facts Himmelstein presented were extremely persuasive and the AMA position — status quo, really — didn’t come anywhere near offering the comprehensive affordable portable coverage of single payer.

Q. How do you describe a single-payer system?

A. Usually I can explain it in seconds. It will cost 4.5 percent in taxes, and there will be no premiums, no pre-existing condition restriction and no tying health care to employment. Because we eliminate health insurance companies and the system is administered by the federal government, we can save $360 billion to $400 billion a year in administrative costs.

Q. How do you counter arguments that the single-payer approach is “socialized medicine?”

A. I have two responses to “socialized medicine.” The usual one that doctors are not employed by the government and the hospitals are independent as well. Also, patients have free choice in our system of doctor and hospital. And they can see doctors here in Portsmouth, go to a specialist in Boston, or if in Florida they can get care there by other private doctors.

Socialized systems employ doctors and they own the hospitals like the VA here or the U.K.

I often ask the question as to whether Medicare is socialized medicine, and the response is usually no. But if they say no, I ask why they wouldn’t want to expand such a wonderful system for seniors to everyone else. And I ask, can you imagine if Medicare didn’t exist today what would seniors do?

If they say yes, then I ask if they would propose eliminating such a ‘socialized’ system and replace it with something else — usually there is not much for them to say.

Q. As a physician, do you see any rationale need for health insurance companies as part of the health-care system?

A. No. People care about their health-care coverage and how much they are paying for it. They don’t care about their health insurance company.

What bothers me is listening to stories like I did at the 2007 Obama health-care forum in Portsmouth — or reading stories everywhere about patients not able to afford care, tests, medicines, or in severe debt because of medical problems.

I contrast that data with the exorbitant profits and multimillion-dollar salaries of some health-care system executives. I often contrast those salaries with the salary of Health and Human Services Secretary (Kathleen) Sibelius — $191,500, for taking care of over 40 million Medicare recipients and over 400,000 patients with renal failure (which makes anyone eligible for Medicare at any age) and anyone with Lou Gehrig’s disease — that is a lot of patients with serious illnesses.

One of the main questions I always come back to is this: Why are our premiums paying for the bonuses of health insurance industry executives? Also, I tell people we are heading for single-payer anyway, and what matters is if we want the government to administer it or for-profit insurance companies running the show, even more than they already are?

Q. What do you hope to accomplish?

A. We should be able to do side-by-side comparisons to see what’s best for the country. If our plan falls short, then fine, and at least we’ve had a debate. But so far Congress has mostly been doing the work of the health-care industry.

For example, a few weeks ago the health-care industry announced it could come up with $2 trillion in savings over 10 years. But a single-payer plan would conservatively save more than $3.5 trillion over 10 years. Why aren’t more politicians giving it (single-payer) further study if cost savings are a top priority?

We are seeing more support across the country as people become aware of what’s happening.

Q. What is your minimum hope for this round of health-care reform?

A. At a minimum, I would like to see Medicare expanded to cover the spouse of a person who is turning 65 and entering the Medicare system. Commonly, a spouse who is several years younger can have medical issues which do not allow them to buy into the individual market. I would give them the choice of buying into the Medicare program at that time of enrollment at the current per capita cost of Medicare. Retirement and a lifetime of savings can be quickly destroyed by a medical illness.

http://nhbr.com/apps/pbcs.dll/article?AID=/20090605/PEOPLE/906039958