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It is time for Medicare for all

By Ahmed Kutty
Kearney Hub
11/03/2008

With an economic meltdown under way and a new president and a new Congress about to be in charge of our country, time is now for Americans to demand a publicly funded health care financing system of universal, comprehensive and equitable coverage against illness.

The U.S. Constitution confers the responsibility “to form a more perfect union … , promote the general welfare and secure the blessings of liberty,” on our elected government.

Our current system of financing health care costs has been very inefficient, terribly expensive and often unresponsive to the needs of the people when stricken by illness, primarily because it is a for-profit, investor-owned and a fragmented-patchwork system, but with the singular exception of Medicare, which is run as a non-profit service-oriented organization for Americans over age 65.

It’s overhead is in the single digits, while in the private system approximately 35 cents out of each health care dollar is spent on the company expenses, including exorbitant CEO salaries, and only 65 cents per premium dollar is available for direct patient care expenses.

The SCHIP program for children was a success until its recent demise by defunding. For working-age Americans, keeping health care insurance as an employer responsibility has been a failure, both for the employees and the employers, including big corporations and small-business owners, with skyrocketing costs making them non-competitive in a globalizing world, especially the industrialized world where some version of a publicly funded health care system is available to all their citizens.

The United States is the lone outlier in this context.

Medicare is not for free, as the free-market fundamentalists would have us believe, nor is it government run. Just as for the private insurance plans, everyone pays a premium via the federal withholding tax and after age 65, the premium is billed directly to the beneficiaries of the program.

Choice of doctors and hospitals has never been fettered, ever since President Lyndon Johnson signed the law in the fall of 1965. Over the past 40-plus years with modifications and regulations put in place, the program is enormously popular with senior Americans, and is a success story.

This was a part fulfillment of President Harry Truman’s effort to introduce a national health care system in the late 1940s and represented a belated big step toward what FDR called “a minimum of the promise that we can offer to the American people” in his address to Congress as it adjourned in December 1933.

Now fast forward to the early Bill Clinton presidency and we find an attempt to introduce a national health care insurance system, under Hillary Clinton’s leadership, fail for lack of political will.

This fall the California Legislature passed a bill, SB840, piloted by state Sen. Sheila Kuehl, providing for an expanded Medicare for all-style single-payer health insurance plan, only to be vetoed by Gov. Arnold Schwarznegger.

This time, we the people should settle for nothing less than a comprehensive national single-payer system, which means Medicare for all. We must work to create a constituency to get the necessary legislation passed by the next Congress and signed by the new president, regardless of party affiliation.

This year’s momentous election will have a long-lasting positive effect on the crisis of health care financing, a major concern of the electorate, if the next Congress takes up the proposal/bill that Sen. Ted Kennedy, from his sick bed is working on, behind closed doors in the Dirksen Senate Office building, a measure Kennedy called, “the cause of my life.”

We shall have them not resuscitate the current failed system, and we will forge the political will necessary for our elected leaders to do the right thing, by raising the voice of an aroused public conscience, that shall be heard loud and clear in the corridors of power.

As true patriots, we will have them treat health care as a right, not a privilege, and not as a commodity but as part of our social compact. Surely a bulwark of “the American Dream” must include a measure of security against vagaries of illness, collectively provided, with risk spread over three hundred million Americans, in this great nation of ours, the most affluent on the earth.

Ahmed Kutty, MD, FACC, of Kearney is a member of the American College of Physicians, which supports the single payer plan.

Choices in coverage during open enrollment

Health insurance shoppers, be wise

By Bobby Caina Calvan
The Sacramento Bee
November 3, 2008

For those fortunate enough to have health insurance, let the head scratching begin (during open enrollment): Option 1 or Option 2? Routine, Choice or Select? PPO or HMO?

Experts say the year-end ritual is an oft-neglected process that deserves focused consideration from consumers, many of whom race through the insurance paperwork with utter terror.

Their decisions have far-reaching consequences.

“It can become a very expensive mistake if they go eenee, meenee, mynee, moe,” said Patricia Feathers, a customer service agent at Placer West Insurance Services in Lincoln. “Making the right choice means staving off bankruptcy and getting the right coverage.”

An ill-informed decision during open enrollment is usually locked in for a year, sometimes more.

But only one in 10 people express confidence in their understanding of their health coverage, according to another survey by the insurer CIGNA.

“When I talk to people, the problem over and over again is that people don’t have the knowledge they need to make an informed decision,” said Karen Kocher, CIGNA’s chief learning officer.

Employees often “default into their existing plans, opt for the cheapest plan, thinking they will save money in the long run.”

The better strategy, experts say, is to have a realistic assessment of health care needs, including an honest look at where health care dollars were spent in the previous year.

http://www.sacbee.com/101/story/1365091.html

Comment:

By Don McCanne, MD

What health insurance coverage will you need next year? Do you determine that by taking an honest look at where health care dollars were spent in the previous year? You are healthy, your health care spending has been negligible, so do you opt for the least expensive plan?

What about next year? Will you have a heart attack? Will you rupture an intracranial aneurysm and require prolonged rehabilitation services? Will you experience the onset of diabetes? Will an unpredictable accident result in extensive injuries, perhaps with permanent neurological impairment? Will you develop an autoimmune disease such as lupus? Multiple sclerosis? Will you develop cancer? If so, which cancer and how involved and protracted will the treatment program be?

Next year’s medical catastrophe, whether acute or chronic, can belong to any of us. That is why everyone of us requires a program that would enable us to access the health care that we need without having to face a financial catastrophe as well. That is a program that everyone would want, if they could afford it.

So why do 90 percent of people lack confidence in understanding their health coverage options? Well, they are confusing. None of the options offer full coverage for everything. All of them attempt to keep the premiums affordable by reducing what is covered. There are endless variations in lists of authorized providers, benefits covered, deductibles, co-payments, coinsurance, tiering, payment caps, and other features that are impossible to sort out when you don’t even know what your needs will be.

What they have in common is that they all decrease, to varying degrees, the security that your health care coverage will provide. You are asked to place a bet now. A larger wager will provide somewhat more security, but none of that wager can be recovered if you end up not needing medical care, which makes you pause before you select that option. (HSAs are not an exception since they are merely segregated savings accounts and not pooled-risk funds; someone else’s HSA would not pay your medical bills.) A smaller wager puts less of a crimp in your budget, but at the cost of losing the security of not being exposed to significant medical debt should the need for care arise.

When all of us want a plan that will provide us with the care that we need, when we need it, without having to face financial penalties for being sick or injured, we really need only one day of open enrollment: the day that we are born. That is the day that each of us would be enrolled in a single payer national health program that is open to all of us forever.

Who Has the Better Health Plan?

The New York Times
Letters to the Editor
Published: November 1, 2008

To the Editor:

“The Candidates’ Health Plans” (editorial, Oct. 28) reveals the critical flaw in both candidates’ proposals. Both merely redistribute the cost of health care; neither actually lowers the cost. Their common flaw: continued dependence on insurance companies.

Here’s a better plan: a single national nongovernment not-for-profit health insurance company financed by a payroll tax. By eliminating the profit margin and cost of marketing, we can reduce the cost of health insurance, and thus health care, dramatically.

Glenn Alan Cheney
Hanover, Conn., Oct. 28, 2008

To the Editor:

Your editorial accurately describes the candidates’ plans. But it doesn’t reveal how inadequate they are.

In the face of a doubling of health care costs just since 1999, they propose nothing that would seriously contain costs or assure access to health care for the millions of Americans, both insured and uninsured, who today are one illness away from bankruptcy.

These plans continue to rely on a privately run insurance system that has shown itself to be too costly, too inflation-prone and too unreliable to meet our needs. As a result, they fail to provide the major system overhaul that the American people need and have been demanding.

Only a complete restructuring of the way we pay for health care, toward a publicly financed system that can assure access to care — much as Medicare does today for those over 65 — while containing costs can truly provide the solid foundation we need for the health care system of the future.

Leonard Rodberg
New York, Oct. 28, 2008

The writer is research director of the New York metro chapter, Physicians for a National Health Program.

To the Editor:

No proposal for the delivery of health care in the United States will make a difference unless somewhere in the debate single payer (Medicare for all) figures in.

Americans must ask an important question: Who would be a more beneficent provider of health care, a well-financed nonprofit national program, or for-profit insurance companies whose primary responsibility is to shareholders and not patients?

Only through a government-sponsored Medicare-for-all model will every resident be guaranteed the basic health care that is the right of all of our citizens, privileged or not.

Richard L. Stivelman
Salisbury, Md., Oct. 28, 2008

The writer is a medical doctor.

To the Editor:

While Senator Barack Obama’s health care plan is certainly sounder than Senator John McCain’s, it is far from what it needs to be if the goal is for all Americans to have quality, affordable health care.

In order to achieve that, we would need single-payer national health insurance, like almost every other industrialized nation has.

Barack Obama used to support a single-payer system, in which health care is publicly financed but privately delivered, as it is in Medicare. Unfortunately, on the way to becoming mainstream enough for the presidency, he stopped talking about single payer and now proposes a system that would preserve the role of for-profit insurance companies, with their administrative excesses.

Mr. Obama should know that as long as private insurers are allowed to waste our premiums finding ways to deny care and deliver dividends to shareholders, universal health care in the United States will never happen.

Sarah Ramer
Pittsburgh, Oct. 28, 2008

The writer is a second-year medical student.

Medical costs still burden many despite insurance

Mass. survey finds people in debt, skimping on care

By Kay Lazar
Boston Globe
October 23, 2008

Although far more Massachusetts residents have health insurance coverage than residents nationwide, a significant portion of Bay Staters are still struggling to pay for needed healthcare, a new survey shows.

Some are postponing treatments, and others are not filling prescriptions, because of high costs or an inability to pay bills from earlier procedures, according to the survey by The Boston Globe and the Blue Cross Blue Shield of Massachusetts Foundation.

A third of those surveyed said the cost of care is their biggest health concern, and 39 percent ranked it among their top two health concerns. No other concern came close.

Thirteen percent of residents with insurance said they were unable to pay for some health services in the past year. The same percentage of insured people said they did not fill at least one prescription because it was too expensive or their insurance copayment was too high. The numbers rise to 14 percent if both insured and uninsured residents are considered.

Two years into the state’s pioneering healthcare experiment to insure nearly everyone, coverage is almost universal, with 97 percent of Massachusetts adults reporting they have some sort of insurance, according to the survey. Yet for some that did not translate into getting needed care.

“Basic things, like getting Flonase, [a sinus medicine] are a luxury,” said Diane Schilder, a 44-year-old Arlington mom and adjunct college professor of education who has two children, a doctorate, health insurance, dental insurance, and about $800 of medical debt on her credit card.

Schilder is one of 506 adults surveyed in the telephone poll conducted Oct. 12 to 17 by the University of New Hampshire Survey Center. The margin of error is plus or minus 4.4 percentage points. Schilder is divorced, but still covered under her former husband’s insurance, which carries a $500 family deductible for prescriptions and then covers only 50 percent of the costs for many drugs, she said.

Such insurance coverage is not unusual. “Many of the policies out there have such huge copayments and deductibles that people can’t afford care,” said Dr. David Himmelstein, associate professor of medicine at Harvard Medical School and a primary care doctor at Cambridge Health Alliance.

Himmelstein is cofounder of Physicians for a National Health Program, an organization that pushes for national health insurance. He studied personal bankruptcies nationwide in 2001 and found that about half of them were linked to a medical issue, and in three-quarters of those cases, the debtor was insured.

While medical debt is burdening a sizable number of Massachusetts residents, the pain is greater nationally, where the percent of uninsured is about five times greater, according to the latest US Census.

A national poll released this week by the Kaiser Family Foundation, a California-based nonprofit that researches health policy, found that about a third of Americans surveyed reported that their family had problems paying medical bills in the past year and that almost one in five said they had medical bills of more than $1,000.

Healthcare leaders say the state’s first-in-the-nation law, which requires nearly everyone to have health insurance or face a tax penalty, has mitigated some cost concerns for consumers.

“It may be that while you are seeing those problems in Massachusetts, they are not as high as what we are seeing nationally because in Massachusetts people do have access to healthcare,” said Drew Altman, Kaiser president and chief executive officer.

Dr. JudyAnn Bigby, Massachusetts secretary of health and human services, said prescription costs can be prohibitive, especially for low-income residents who have chronic health problems and need several medications. She said the state is considering eliminating or greatly reducing the $1 copayments for thousands of residents on Medicaid who need medications to treat diabetes or high blood pressure or cholesterol.

“It would make it more affordable for people with chronic medical conditions to take multiple medications and . . . manage their conditions better,” she said.

Still, she said, fewer residents overall are struggling with medical bills since Massachusetts overhauled its healthcare laws two years ago. She cited a recent survey by the Urban Institute, which found that the share of people with skimpy health insurance that left them with huge medical bills has dropped two percentage points since the state’s new law started.

It also found that such inadequate insurance is a problem for three times the number of people nationally, compared with Massachusetts. Starting in January, the insurance coverage mandated by the state will have to include prescription drugs.

The Globe-Blue Cross survey found that income has a direct correlation to a household’s ability to afford care. People with household incomes less than 300 percent of the federal poverty level, roughly $31,200 for a single person, were more than twice as likely to report problems affording prescriptions or other care. People who are divorced or who never went beyond high school were also more likely to report healthcare cost problems.

Among those reporting difficulty was Harvard University graduate student Justin Vincent, 26, a brain researcher who was stuck with a $3,000 bill last year after breaking his leg because his health insurance did not cover the physical therapists recommended by his doctor.

“After the leg surgery, I generally refuse medical care because they don’t tell you what the prices are,” he said. “It’s not like Walmart, where they tell you what the prices are.”

The Globe/Blue Cross survey found that 8 percent of people with insurance and 9 percent overall reported avoiding or postponing medical treatment because they already owed money for health services. In Blackstone, Robert Ravenelle, 20, a private security guard who makes about $10 an hour, said he is still paying off a $1,400 emergency room bill from last year for a knee injury because he doesn’t have health insurance. Ravenelle said he has received warnings from the state about facing a tax penalty for not having coverage, but has decided paying the penalty is less expensive than buying insurance.

“Unless they want me to live on the street,” he said, “I can’t do it.”

The Blue Cross Blue Shield Foundation recently launched a project studying how state residents get care.

Kay Lazar can be reached at klazar@globe.com.

http://www.boston.com/news/local/massachusetts/articles/2008/10/23/m

Where is bailout for U.S. health-care system?

Rose Ann DeMoro
Palm Beach Post
Letters to the Editor
Monday, October 27, 2008

If we can take ownership of our banks, why not a similar approach for our imploding health-care system? In homes across America, our health-care system is dying a quiet death. The millions who endure their pain away from the spotlight of Wall Street deserve sweeping systemic solutions as well.

Leslie Elder of West Palm Beach was hit with $70,000 in bills for surgeries for kidney cancer. Susan Christensen of Altamonte Springs had to fight with her insurer to cover her choice of where to give birth to her child, as required by Florida law.

Last week, the Census Bureau found that up to 30 percent of South Floridians under 65 are uninsured. The news isn’t so great for those with insurance, either. Another report in The Wall Street Journal noted that employers are expected to increase out-of-pocket costs to workers by more than 10 percent next year. Perhaps most shocking is the story in USA Today that one of every eight patients with advanced cancer turned down recommended care because of the cost.

If we can bail out our financial system, why can’t we do the same for the tens of millions of Americans facing bankruptcy and health-care calamity? Through the simple, cost-effective approach of improving and expanding Medicare to cover everyone, the U.S. could nationalize the financing of health-care delivery, a single-payer system, while leaving intact the most private system of hospitals and doctors.

What moved the Bush administration to take the partial nationalization approach was the example of Great Britain that has broad support among other industrialized nations. Residents in nearly all those other countries at least have less worries about their health security. Sadly, we rank last among 19 comparable industrial nations in preventable deaths, according to a report by the Commonwealth Fund. The main difference is that those nations have a nationalized or single-payer health-care system, such as U.S. Medicare.

Health care is now the second top issue of concern in the national election, trailing only the economic disaster. As Barack Obama said in the second debate, health care “should be a right for every American.” If we can rescue the banks, surely we can rescue the rest of America, starting with our health.

Editor’s note: Rose Ann DeMoro is executive director of the National Nurses Organizing Committee/California Nurses Association, www.guaranteedhealthcare.org

http://www.palmbeachpost.com/opinion/content/opinion/epaper/2008/10/27/mondaywebletters_1027.html

Universal health insurance now

Editorial
The Daily Gazette (Schenectady, NY)
Friday, October 24, 2008

Americans will survive a protracted economic downturn if they have to forgo luxuries like daily lattes at Starbucks or new flat-screen TVs. But many will not make it if they continue to skimp on health care, as a story in last Friday’s Gazette indicated they’ve been doing. Stories like that — another one appeared on the front page of Wednesday’s New York Times — make the best argument yet for the government to provide universal health insurance. Left to their own devices and dwindling resources, too many Americans can’t or won’t buy it themselves.

The story contained numerous anecdotes of people who had declined or delayed trips to the doctor, stopped or cut back on prescribed medication, etc. due to money issues. In one, a woman ignored a lump on her breast that, when she finally went to the hospital complaining of back pain, proved to be cancer.

According to a survey by the Rockefeller Foundation and Time magazine released this summer, the number of Americans who skipped a visit to a doctor because of cost rose from 18 percent to 25 percent in just the last year. Obviously, that number is likely to rise further as the recession worsens. And while some people may “get away with it,” others who have more serious ailments will get sicker. The eventual cost of curing them will be much higher and, more likely than not, will be borne by the public.

It would be much more humane, as well as cost-effective, to get these ailments fixed before they become serious or even terminal. But without a program that provides comprehensive coverage at little or no cost, millions of Americans will continue to play Russian roulette. What’s needed is a single-payer system, a la Medicare, that covers everyone equally. The government may not be the most efficient administrator when it comes to such programs, but it’s hard to imagine anything worse than the current system, with hundreds of middle men (HMOs, private insurers, etc.) each with their own costly bureaucracies.

AMA position on single payer

Frequently asked questions about the AMA proposal for reform

American Medical Association
October 2008

Q: What are the basic principles of the AMA proposal?

A: The American Medical Association (AMA) proposes that individuals and families receive financial assistance to purchase a health plan of their choice, with more generous assistance to those with lower incomes. The financial assistance could take the form of tax credits or vouchers and must be earmarked for health insurance coverage. Health insurance market regulations should be reformed to establish fair “rules of the game” that protect vulnerable individuals, without unduly driving up premiums for the rest of the population.

Q: How is the AMA proposal different or better than a single-payer system?

A: Both the AMA and the single-payer approaches emphasize the same goal of universal coverage, but they differ on how to implement it. The AMA does not believe that full government control is a workable model for the United States. Single-payer systems are plagued with an undersupply of medical personnel, long waiting periods and a lack of patient choice. Alternatively, the AMA proposal seeks to enhance patient choice and encourage patients to be conscious of health insurance costs, while also maintaining innovation in the private sector.

http://www.voicefortheuninsured.org/pdf/08-1103-FAQ-Proposal.pdf

Comment:

By Don McCanne, MD

The AMA is trying. During this presidential election season, the AMA has initiated an intensive “Voice for the Uninsured” campaign in support of their model of reform. Unfortunately, the policies behind their version of reform would fall far short of achieving the goal of affordable, comprehensive health care for everyone. Their feeble and deceptive effort to explain why their proposal is better than single payer reveals the fact that that the AMA is still controlled by those ideologically opposed to a national health program.

One of their basic principles is that “insurance market regulations should be reformed to establish fair ‘rules of the game’ that protect vulnerable individuals, without unduly driving up premiums for the rest of the population.” Presumably insurance market regulations that protect vulnerable individuals would mean that plans must prevent financial hardship for those who need health care. Even the average employer-sponsored family plan (at $12,600) may not be adequate because of deductibles and other cost sharing requirements. To be effective in protecting personal finances, these plans must be quite comprehensive and will require very high premiums.

Yet the AMA states that these plans must not unduly drive up premiums for the rest of the population. That is an impossibility. The only way you can keep premiums low is to segregate the healthy in isolated risk pools (but then these pools wouldn’t work for those who end up needing medical care because of the high cost sharing used to keep the premiums low). If you were to isolate those with high medical expenses in pools providing comprehensive coverage, the premiums would be so high that the many who are healthy would have to finance most of the costs.

Of course that is why the AMA has recommended taxpayer financed subsidies to help pay those premiums. But how could you ever make that equitable? Imagine the complexities of setting premiums in a fragmented system of unstable and inequitable risk pools, and then providing tax subsidies (credits or vouchers) that would vary with ever changing income levels. And for that we would continue to accept private insurance plans that burn up hundreds of billions of dollars in administrative waste, while remaining incapable of directing our health care dollars to where they would do the most good. Supporting a model with excess costs and greater inefficiency doesn’t make sense.

Regarding single payer, the AMA labels that as “full government control.” It is hard to know what that means when the health care delivery system remains private. About sixty percent of our health care is already financed through taxes. Single payer systems typically finance about seventy percent (though more would improve efficiency). “Full government control” is merely intended as a pejorative label that has little policy application. That label could backfire on the AMA since many Americans are now concerned that the government has not been doing enough.

The AMA states that single payer systems are “plagued with an undersupply of medical personnel.” Massachusetts has a program not unlike that supported by the AMA. Tell the people of Massachusetts that the primary care physicians that they can’t find are really there in great supply. Tell the patients behind the curtains in the upstairs hallways that we don’t have an undersupply of safety-net beds. Tell the patients on Medicaid or in Community Health Centers that we don’t have an undersupply of willing specialists. Tell the ambulance drivers who are waved past full emergency departments that we don’t have an undersupply of emergency facilities. The fact is that publicly administered programs are more capable of identifying needs and redirecting resources to where they would do the most good.

The AMA says that single payer systems cause long waiting periods. Tell that to the tens of millions of individuals in the United States who are not even allowed a place in the queue. Tell that to insured patients who may have to wait months for an appointment with a specialist. Tell that to the authors of the OECD report which demonstrated that many nations with public systems have been successful in reducing and even preventing excessive queues.

The AMA says that single payer systems cause a lack of patient choice. What does that mean? Most private insurance plans have restricted lists that take away our choice of hospitals, physicians, and other health care professionals. A single payer system gives you this free choice within the health care delivery system. Does the AMA mean a lack of choice of health plans? The only plan that you really want is a plan that allows you to access health care without being assessed a financial penalty for having health problems. Most private health plans do not do that, but a single payer system does.

The AMA states that their proposal, unlike single payer, encourages patients to be “conscious of health insurance costs.” If you look at our individual insurance market where people select their plans based on the amount of the premium, it’s easy to understand what a flawed concept this is. We have had an explosion in innovative underinsurance plans that have left patients with major medical debt, home foreclosures, and even personal bankruptcy. These people are certainly “conscious” of the financial hardship that the private plans exposed them to.

I’m the first to admit that the “Voice for the Uninsured” campaign offers real hope that the AMA has had an epiphany. But that hope will be dashed once again unless the AMA backs up their campaign with sound health policy science.

Medical tourism causes complications

Medical Tourism Causes Complications

By Christina L. Madden
Carnegie Council
Policy Innovations
October 27, 2008

Approximately 750,000 Americans traveled overseas for medical treatment in 2007, and the number of so-called medical tourists could increase to more than 15 million in 2017.

Overall the effects of medical tourism are mixed. On the one hand, the industry can boost a developing country’s gross domestic product and investment in health facilities. Upgrades in a country’s hospitals also tend to decrease external brain drain, as top physicians find local jobs instead of leaving for employment in developed nations.

In many cases, however, medical tourism threatens to exacerbate unequal access to quality health care in developing countries. Although relatively cheap by most Western standards, the private hospitals that treat foreigners are out of reach for the majority of people, and the revenue they bring in rarely makes its way to the public sector.

External brain drain is often replaced by internal brain drain, as doctors leave public health care centers to work in private hospitals.

Medical tourism is not an alternative to significant reform of the U.S. health care industry. Aside from the negative effects on public health overseas… medical tourism is not predicted to reduce the country’s health spending by more than 1 to 2 percent.

By introducing global competition to an industry that’s long been considered immune to outsourcing, medical tourism may up the ante on reforming coverage, cost, and quality at home.

http://www.policyinnovations.org/ideas/briefings/data/000083

Comment:

By Don McCanne, MD

Previous studies have shown that one of the reasons that health care is so expensive in the United States is that, quite simply, our prices are very high. Since other nations have been demonstrated to be capable of selectively providing high quality care at much lower prices, it is not surprising that medical tourism has become an attractive option for those paying the bills, including cash-paying patients, some insurers and some employers.

For those who believe that health care financing should be a function of markets, medical tourism would have a prominent place in the menu of options. For those who believe that health care systems should provide everyone with the best options available in an egalitarian system, both for us in the United States and for the people of other nations, medical tourism is a troublesome development.

As this article describes, medical tourism is further impairing public health programs in developing nations. In our quest for a high performance system in the United States, we must be very careful to avoid the unintended consequence of inflicting damage on the health systems of other nations.

The World Health Report 2008

Primary Health Care – Now More Than Ever

World Health Organization
October 14, 2008

The World Health Report 2008 critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The WHO report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.

Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.

To steer health systems towards better performance, the report calls for a return to primary health care (PHC), a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment.

This report structures the PHC reforms in four groups that reflect the convergence between the evidence on what is needed for an effective response to the health challenges of today’s world, the values of equity, solidarity and social justice that drive the PHC movement, and the growing expectations of the population in modernizing societies: reforms that ensure

* that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection — UNIVERSAL COVERAGE REFORMS;

* reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes — SERVICE DELIVERY REFORMS;

* reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors — PUBLIC POLICY REFORMS;

* reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems — LEADERSHIP REFORMS.

In high-expenditure health economies, which is the case of most high-income countries, there is ample financial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established universal coverage system with targeted measures to reduce exclusion.

Even in the United States, its exceptionalism stems not from lower public expenditure… but from its singularly high additional private expenditure. The persistent under-performance of the United States health sector across domains of health outcomes, quality, access, efficiency and equity, explains opinion polls that show increasing consensus of the notion of government intervention to secure more equitable access to essential health care.

http://www.who.int/mediacentre/news/releases/2008/pr38/en/index.html

Primary Health Care – Now More Than Ever (148 page PDF):
http://www.who.int/whr/2008/whr08_en.pdf

Comment:

By Don McCanne, MD

The World Health Report 2008 provides a critical assessment of health care systems throughout the world. It describes how all nations, regardless of national wealth, can benefit by enacting reforms organized around primary health care.

In reading the various experiences of other nations, it is almost shocking to see how infrequently the most expensive health system of all, that of the United States, is mentioned as an example of how reform can work. But then it is understandable when other nations single our system out for its exceptionalism – a system with “singularly high additional private expenditure” that persistently underperforms “across domains of health outcomes, quality, access, efficiency and equity.”

For a proper perspective of what we do have and what we could have, this report should be required reading.

California's high-risk pool is sick

California high-risk pool for medically uninsurable helps fewer residents

By Jordan Rau
Los Angeles Times
October 28, 2008

California… is one of 35 states that arranges health coverage for people rejected by commercial companies because they have blemished medical histories.

This group — known as “medically uninsurable” — accounts for about an eighth of the 5 million Californians who lack health insurance. Most are self-employed, work for companies that don’t provide insurance or don’t have a job.

But California’s publicly subsidized high-risk pool, long one of the least generous in the country, has atrophied over the tenure of Gov. Arnold Schwarzenegger — even as the governor put the plight of the uninsured at the top of his political agenda.

Rising premiums and limited subsidies have made the Major Risk Medical Insurance Program either unaffordable, unavailable or ineffective for many of those who most need health insurance.

The program now covers about 13,000 Californians — about 2% of the medically uninsurable.

Enrollment has dropped by almost a third since Schwarzenegger became governor.

Subscribers pay two-thirds of the pool’s cost and the state about one-third. The insurers that voluntarily participate — primarily Blue Cross of California and Kaiser Permanente — break even.

Unlike most other states, which finance their programs either directly with tax dollars or with assessments on insurers, California’s subsidies have come only from the state’s tobacco tax.

Lawmakers have kept annual financing at or below $40 million a year, requiring the pool’s administrators to cap its enrollment.

One of the major obstacles is the cost of premiums, which the law sets at 125% of commercial insurance rates. More than a third of pool participants who dropped out this year told the pool’s administrators that they couldn’t afford it anymore.

Despite its cost, California’s high-risk pool is of limited use for people needing extensive medical care, such as those with cancer or chronic diseases. That is because the pool’s benefits are capped at $75,000 a year, lower than the limits of any other state’s pool.

To fix California’s pool, the Legislature this year proposed placing a $1 monthly per customer fee on insurers that sell policies directly to customers.

But in his veto message, Schwarzenegger said the fee would be passed on to customers and thus “only exacerbates their burden.”

http://www.latimes.com/news/local/la-me-uninsured28-2008oct28,0,7559850,full.story

Comment:

By Don McCanne, MD

The concept of health insurance is quite simple. When everyone pays into an insurance risk pool, the many who are healthy are subsidizing the higher costs of those with greater health care needs. Thus everyone receives whatever medical care they need without facing financial barriers to care.

Then why do we have high-risk pools? The simple answer is that health care has become so expensive that premiums for universal pools would be so high that few could afford them. So we move higher cost individuals into high-risk pools in order to keep premiums more affordable for pools of healthy individuals.

Think about the premium for a family in an employer-sponsored pool composed of the healthy workforce and their young healthy families; it now averages $12,600. If we were to add into these pools many hundreds of thousands of individuals with high health care costs, you can only imagine how high the premiums would go.

Although California has set the high-risk pool premium at 125 percent of commercial rates, they have had to cap the benefits at $75,000 to avoid yet higher premiums. Sorry, but for this high cost group, that falls far short of the insurance function of preventing financial hardship in the face of medical need. For adequate benefits, the premiums for high-risk pools would be unaffordable for all but the very wealthiest of us, as if they weren’t too high already.

If we expect to cover high-risk individuals, we do need a transfer from the healthy to the sick. California attempted to take a very small step in this direction by assessing fees on insurance plans in the individual market that would be used to help fund the high-risk pool. But Gov. Schwarzenegger didn’t want to “exacerbate the burden” on the healthy by expecting them to help fund care for the sick. Then who funds the high-risk pool?

We really need to end this game of juggling unaffordable premiums amongst fragmented, inequitable risk pools. It’s time to establish one single risk pool for all of us, and fund it equitably through progressive taxes. The private plans get in our way. We need to dump them.

California’s high-risk pool is sick