PNHP

Census Bureau on the uninsured

pnhpf3a

Census Bureau on the uninsured

Income, Poverty, and Health Insurance Coverage in the United States: 2007

U.S. Census Bureau
August 2008

What Is Health Insurance Coverage?

For reporting purposes, the Census Bureau broadly classifies health insurance coverage as private coverage or government coverage. Private health insurance is a plan provided through an employer or a union or purchased by an individual from a private company. Government health insurance includes the federal programs Medicare, Medicaid, and military health care; the State Children’s Health Insurance Program (SCHIP); and individual state health plans. People were considered “insured” if they were covered by any type of health insurance for part or all of the previous calendar year. They were considered “uninsured” if they were not covered by any type of health insurance at any time in that year.

Highlights

* Both the percentage and number of people without health insurance decreased in 2007. The percentage without health insurance was 15.3 percent in 2007, down from 15.8 percent in 2006, and the number of uninsured was 45.7 million, down from 47.0 million.

* The number of people with health insurance increased to 253.4 million in 2007 (up from 249.8 million in 2006). The number of people covered by private health insurance (202.0 million) in 2007 was not statistically different from 2006, while the number of people covered by government health insurance increased to 83.0 million, up from 80.3 million in 2006.

* The percentage of people covered by private health insurance was 67.5 percent, down from 67.9 percent in 2006. The percentage of people covered by employment-based health insurance decreased to 59.3 in 2007 from 59.7 percent in 2006. The number of people covered by employment-based health insurance, 177.4 million, was not statistically different from 2006.

* The percentage of people covered by government health insurance programs increased to 27.8 percent in 2007, from 27.0 percent in 2006. The percentage and number of people covered by Medicaid increased to 13.2 percent and 39.6 million in 2007, up from 12.9 percent and 38.3 million in 2006.

* In 2007, the percentage and number of children under 18 years old without health insurance were 11.0 percent and 8.1 million, lower than they were in 2006 — 11.7 percent and 8.7 million. Although the uninsured rate for children in poverty decreased to 17.6 percent in 2007, from 19.3 percent in 2006, children in poverty were more likely to be uninsured than all children.

* The uninsured rate and number of uninsured for non-Hispanic Whites decreased in 2007 to 10.4 percent and 20.5 million (from 10.8 percent and 21.2 million in 2006). The uninsured rate for Blacks decreased to 19.5 percent in 2007 from 20.5 percent in 2006. The number of uninsured Blacks in 2007 was not statistically different from 2006, at 7.4 million.

* The percentage and the number of uninsured Hispanics were 32.1 percent and 14.8 million in 2007, lower than 34.1 percent and 15.3 million in 2006.

http://www.census.gov/hhes/www/hlthins/hlthin07/hlth07asc.html

And…

Number of Uninsured Drops…

By The Associated Press
The Washington Post
August 26, 2008

The Census Bureau reports that the number of people lacking health insurance dropped by more than 1 million in 2007, the first annual decline since the Bush administration took office.

http://www.washingtonpost.com/wp-dyn/content/article/2008/08/26/AR2008082600863.html?hpid=moreheadlines

Comment:

By Don McCanne, MD

The Associated Press story just released on the decline of 1.3 million in the numbers of uninsured will surely be welcome news. It was especially good news for those who gained coverage in 2007. Should we be celebrating? Let’s look at some of the statistics.

* The percentage of people covered by employment-based health insurance declined by 0.4 percent, continuing a downward trend. The foundation of employment-bsed coverage continues to deteriorate.

* The percentage of people covered by government health insurance programs increased 0.8 percent, more than offsetting the decline in employer-sponsored coverage. The net improvement in the numbers is due to an expansion of government programs.

* The percentage of people covered by Medicaid increased 0.3 percent. That amounts to an increase of 1.3 million individuals, which just happens to be the same number as the decline in the uninsured. The chronic underfunding of this program has sacrificed access because of the lack of willing providers. Expanding a program that has perpetuated impaired access does not seem to be a wise policy choice.

* People who were uninsured for only part of the year were counted in this study as being insured. Yet studies have confirmed that having only intermittent coverage impairs access and outcomes.

* This study remains silent on the explosion in the rate of underinsurance, a phenomenon that is difficult to measure anyway. Counting the numbers of people who have insurance coverage provides a very incomplete picture if that coverage does not protect individuals from financial hardship in the face of medical need.

* A slight improvement in the percentages for Blacks and Hispanics is of little consolation when compared to the enormity of these disparities.

Celebration time? Don’t think so.

Doctor's Orders: Health Coverage for Everyone

By Daina Saib
YES! Magazine
Fall 2008: Purple America

An agenda that puts people first: Health Care

You wouldn’t know it from the candidates’ debates or reports on the major television networks, but a majority of Americans favor a government-run health insurance system similar to Canada’s.

Those lining up to support single-payer health care include medical professionals, business people, and many Republicans. Dr. Rocky White has been all of those things.

White is a former Republican, from a conservative, evangelical background, who got interested in health care reform nine years ago when his own medical practice slipped into the red. His research into the health care system led him to conclude that the problem wasn’t just in his practice– the health care system itself is broken, and a single-payer program is the most efficient way to fix it.

Under the single-payer system, doctors’ offices and hospitals remain private for-profit or non-profit institutions. But the federal government covers the bills for patient services, with funds coming from taxes. The patient gets the health care they need. Paperwork and billing are kept to a minimum. Employers no longer have the difficult task of choosing, administering, and paying for health insurance for employees. Everyone is covered.

The current setup is as complicated as single-payer is simple. Today, the discerning consumer must wade through a complex system of pre-existing condition exemptions, co-pays, and deductibles–if they have coverage at all. Arguments over billing among doctors’ offices, insurance companies, patients, and their lawyers eat up millions of dollars. An estimated $25 out of each $100 spent goes to paperwork, profits, and executive pay and bonuses. And disagreement over medical coverage is one of the most common sources of labor disputes for employers who have seen insurance premiums double since 2000.

With these inflated costs, it’s little wonder that in 2006, the last year for which government figures are available, 47 million Americans had no insurance at all, including 8.7 million children, or that 68 percent of bankruptcies in the U.S. come as a direct result of medical expenses among people who do have insurance.

When White learned about Physicians for a National Health Program and their plan for a single-payer health care system, he saw it was similar to his own idea and he joined their effort.

Other medical professionals have had a similar reaction. The American College of Physicians–the largest organization of medical specialists in the country–endorses single-payer health care as does the California Nurses Association, the largest organization of registered nurses.

And so do 55 percent of Americans, according to a CBS News poll conducted in September. In another poll, 64 percent said they would be willing to pay higher taxes for a national health care insurance program.

In Congress, HR 676, the “Medicare for All” bill introduced by Representative John Conyers, Jr. of Michigan, currently has 90 co-sponsors–more than any other health care reform proposal–and the endorsement of the U.S. Conference of Mayors.

Republicans for Single-Payer

Support for single-payer health care is not just strong among progressives. George Swan, for instance, is a health care administrator, self-described “Purple Republican,” and a founder of Republicans for Single Payer.

“It’s about being American and doing what’s right,” Swan says. “What’s right is not paying a 30 percent premium to the insurance system and receiving sub-standard health care.”

Business owners are also supporting single-payer health care. For 25 years, Jack Lohman owned a company that provided cardiac monitoring services to hospitals. Today, he’s a co-founder of the Business Coalition for Single Payer. A “lifelong Republican,” Lohman argues that conservatives should support single-payer because it’s pro-business.

“For the same 16 percent of GDP that we are spending on health care in the U.S.,” he says, “we could provide first-class health care to 100 percent of the people.” And single-payer would “get health care off the backs of corporations so they can be more competitive with products made overseas.”

John Arensmeyer spent 12 years running an e-commerce company with 35 employees. Then he founded the Small Business Majority to advocate for the interests of small businesses, particularly on health care issues. Sharp rises in health care costs for small businesses are hurting their ability to survive, Arensmeyer says. “It’s antithetical to what we’re all about as a country, which is to allow people the freedom to go out and start new enterprises.”

Small business has often been portrayed as opposing health care reform, but SBM’s research shows that small businesses are interested in being part of the solution–even if it means paying higher taxes.

Walter Maher, former vice-president of public policy at the DaimlerChrysler Corporation, sees the problems in similar ways, although he looks at health care costs through the lens of large corporate employers.

General Motors, he says, is paying people to leave their jobs so they can hire replacements at 50 cents on the dollar with reduced health benefits. “It’s sad,” he says. “You have a giant albatross around your neck because you choose to provide a good standard of living for your employees.”

Money in Politics

If the current system is so unpopular among medical professional, patients, and business owners, what’s keeping it in place? Most advocates for single-payer agree that money in politics is the greatest obstacle to change. During the 2006 election cycle, the health care industry spent $99.7 million on campaign contributions. Lobbying on health care issues topped $446 million in 2007.

For Jack Lohman, that’s the crux of the problem. “Both McCain’s and Obama’s plans for health care are lousy,” he says. “Although both claim they’re not taking lobbyist money, somehow this money is getting through. They are each supporting health care that keeps the insurance industry involved.”

And all that money can buy a lot of misinformation and scaremongering. Rocky White says he finds that people get interested in the single-payer approach if they understand what’s actually being proposed: “When people realize that all that it is,” he says, “is a publicly owned insurance company, all of a sudden business people start to lose that fear that ‘Oh my God, we’re going to become the Soviet Union.’ Even Republicans say, ‘This really makes a lot of sense.'”

While White would like to see reform happen on a national level, he believes it’s more realistic to work at the state level for now. And for him, that means Colorado. White sits on the board of Health Care for All Colorado, a nonprofit, volunteer-run group with 250 members that includes Democrats, Republicans, physicians, business people, college professors, and economists. And he is running for a Democratic seat in the state legislature to add “the voice of medicine” to the debate.

“Any time a state has studied it, they find that single-payer is the most cost-effective and covers everyone,” White says. His proposal for a single-payer system in Colorado is being studied by a blue ribbon commission created by the Colorado Legislature.

In May, the 6,000 delegates to the Colorado Democratic Party Convention endorsed a pro-single-payer resolution that will be forwarded to the national convention in Denver in August.

If one state can make a single-payer plan work, White believes, it could start a cascading effect similar to what took place in Canada during the 1940s and ‘50s.

“People are discouraged, they’re angry, they’re upset,” White says. “But politics is the process that drives policy, and if we don’t get involved in the political process we’ll never make a difference.”

Daina Saib wrote this article as part of Purple America, the Fall 2008 issue of YES! Magazine. Daina is a former YES! editorial assistant.

Slight drop in uninsured masks deepening problem, doctors say

For Immediate Release
Aug. 26, 2008

Contact:
Don McCanne, M.D., don@mccanne.org

Data released this morning by the Census Bureau showing a slight drop in the number of Americans who lacked health insurance in 2007 masks an acute and worsening problem of access to care, a national doctors’ group said today. The figures also do not reflect the harmful consequences of this year’s economic downturn, the group said.

Census officials reported that the number of uninsured dropped from 47 million in 2006 to 45.7 million in 2007, or by half a percentage point (from 15.8 percent to 15.3 percent)

“While any drop in the number of uninsured is welcome news, a closer look at the Census Bureau data for 2007 provides little cause for celebration,” said Dr. Don McCanne, senior policy fellow at Physicians for a National Health Program.

McCanne said the number of people covered by employer-sponsored plans stayed about the same or slightly declined (0.4 percent), continuing a long-term trend of eroding coverage from this traditional source. While 64 percent of the population was covered by employment-based plans in 1999, only 59.3 percent was covered in this way in 2007.

Upon closer examination of the data, McCanne said, it is clear that last year’s gain in the number of insured people was entirely attributable to an expansion of government programs like Medicare and Medicaid. The number of people covered by government health insurance programs increased by 2.7 million. Were it not for this increase, he said, the uninsured numbers would have surpassed the 2006 figure.

“The new figure – 45.7 million uninsured – is still unacceptably high,” he said. “It’s the second-highest figure since the 1960s, when Medicare and Medicaid were enacted into law. We still have at least 8.1 million children who are uninsured, a scandalous figure.”

McCanne said the Census Bureau report is silent on another problem, which he called “the explosion in the rate of underinsurance.” People are typically defined as underinsured if they spend 10 percent or more of their income (or 5 percent if they are low-income) on out-of-pocket medical expenses or if they had deductibles equal to 5 percent or more of their income.

While the number of underinsured is difficult to measure, he said, last June the Commonwealth Fund estimated that 25 million people were in this category in 2007, up 60 percent from 2003. Some health policy experts estimate the number of underinsured to be 50 million.

“Not having health insurance, or having poor quality insurance that doesn’t protect you from financial hardship in the face of medical need, is a source of mounting stress, anguish and poor medical outcomes for people across our country,” McCanne said.

He said African Americans are almost twice as likely to be uninsured as whites, and that Hispanics are three times more likely to be uninsured. While minorities, like whites, posted slight improvements in coverage in 2007, “such gains are of little consolation when compared to the enormity of these disparities,” he said.

Several studies have shown that economic recessions, with their attendant job losses, correlate with an increase in the number of uninsured. For example, a January report by John Schmitt and Dean Baker at the Center for Economic and Policy Research suggests that in a mild-to-moderate recession health insurance coverage is likely to fall 1.4 percentage points, leaving an additional 4.2 million individuals without insurance. A more severe recession would have worse consequences.

Many economists believe a recession began in the U.S. at the end of 2007. As a result, McCanne said, it is likely that the Census Bureau figures present a misleading picture of the current situation. “The continuing high profile of the health care issue in the elections is another index of public anxiety about access to care,” he said.

The growing financial difficulties of the much-touted incremental reforms in Massachusetts, he said, shows that its short-term gains in reducing the number of uninsured are in jeopardy.

McCanne said fundamental health care reform is possible. “What is really needed is a system that removes the financial burden from patients and more effectively pools our funds into a public program that is able to address costs more effectively by introducing greater efficiency and value into our health care system.

“Such a system would guarantee comprehensive health care to everyone by replacing the private insurance industry with a tax-supported government agency or agencies that would pay all medical bills, similar to the way Medicare operates today, but even better than Medicare,” he said. “People would have the freedom to choose their own doctors and hospitals.

“That’s a single-payer system. Such a system is embodied in H.R. 676, the U.S. National Health Insurance Act, introduced by Rep. John Conyers (D-Mich.). It currently has over 90 co-sponsors in Congress, more than any other health reform proposal.”

A table showing the number of uninsured by state for the years 2004-2007 is available here. Physicians for a National Health Program has physician-spokespersons in every state who are available for comment.

###

Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, visit www.pnhp.org/stateactions or call (312) 782-6006.

Cost of covering the uninsured

Covering The Uninsured In 2008: Current Costs, Sources Of Payment, And Incremental Costs

by Jack Hadley, John Holahan, Teresa Coughlin, and Dawn Miller
Health Affairs
August 25, 2008

People uninsured for any part of 2008 spend about $30 billion out of pocket and receive approximately $56 billion in uncompensated care while uninsured. Government programs finance about 75 percent of uncompensated care. If all uninsured people were fully covered, their medical spending would increase by $122.6 billion. The increase represents 5 percent of current national health spending and 0.8 percent of gross domestic product. However, it is neither the cost of a specific plan nor necessarily the same as the government’s costs, which could be higher, depending on plans’ financing structures and the extent of crowd-out.

Incremental resource cost versus transfer or crowd-out costs.

Most important for the policy debate, however, it is essential to differentiate the incremental resource cost of insurance expansion from transfer or crowd-out costs, and from the more thorny issue of the financing of insurance expansion. Incremental resource cost is a key number for assessing the cost-effectiveness of expanding insurance coverage–that is, comparing the value of improved health associated with expanded coverage to its resource cost.

However, the additional cost of care used by the uninsured is not the same as the cost to the government of a coverage expansion, since out-of-pocket spending and income-related premium payments by the newly insured are likely to pay some of these extra costs. Further, the cost attributed to any broad health care financing reform could be much higher, depending on the extent to which people drop their prior coverage in favor of coverage under the new plan or retain their current coverage but receive new public subsidies to help pay their premiums.

These costs are not new national resources being devoted to health care but, rather, represent a transfer of spending from one type of coverage to another: although government spends more, many individuals, families, and businesses spend less. The savings to businesses and families in private insurance premiums and out-of-pocket spending can be large and are often overlooked in health reform cost calculations that focus on increased government spending. How the cost of the subsidies is distributed among different classes of people and geographic areas is at least as major a political issue as the amount of the subsidies.

http://content.healthaffairs.org/cgi/content/full/hlthaff.27.5.w399/DC1

Comment:

By Don McCanne, MD

Previous studies by Jack Hadley and his colleagues have shown that the increase in medical spending that would result from expanding insurance coverage to the uninsured would have been about $55 billion in 2001. For 2008, because of rapid increases in health care costs, continuing growth in the number of uninsured people, and changes in the characteristics of the uninsured population, that estimate has increased to about $122.6 billion. Even at this level, the cost of expanding coverage to everyone would be “remarkably small — about the same as the growth of real health care spending over eighteen months” (Aaron, Health Affairs blog, 8/25).

It is not the lack of funds that has impeded reform. As a nation we could easily afford to cover everyone. So what is the problem?

We already have proven that reform cannot be accomplished by incremental expansions of our current programs, even with introductions of new targeted programs (e.g., SCHIP). The effectiveness and equity of health care financing have continued to deteriorate under the incremental approach to reform. No reform proposal is capable of leaving those with coverage alone while collecting $122 billion and spending it exclusively on those who are currently uninsured.

Only through comprehensive reform could we provide all necessary health care for everyone at a cost comparable to today’s spending. Not just any reform would do. In fact, the policies that we would need to adopt would limit the reform options to some form of social insurance such as a single payer national health program.

Transforming a financing system for a $2 trillion industry inevitably results in winners and losers. Our policies to date have made winners of the entrenched vested interests that have so much to gain (money), while making losers of the patients that the industry should be serving (losing affordable health care access).

It’s time to make patients the winners. That means that a well financed and well managed health care delivery system would also fall into the winners’ category. There will be losers, but, gee, aren’t they already losers anyway?

Markos asked for more; I answer: Obama on Single Payer

by DrSteveB
DailyKos
Thu Aug 21, 2008

Yesterday our great orange leader Markos asked to know more about Obama’s being quoted in the Wall Street Journal as supporting Single Payer national health coverage. Here’s what Obama actually said at the New Mexico event:

“If I were designing a system from scratch, I would probably go ahead with a single-payer system,” Obama told some 1,800 people at a town-hall style meeting on the economy.

[snip]

But Obama repeated that he rejects an immediate shift to a single-payer system. “Given that a lot of people work for insurance companies, a lot of people work for HMOs. You’ve got a whole system of institutions that have been set up,” he said at a roundtable discussion with women Monday morning after a voter asked, “Why not single payer?”

“People don’t have time to wait,” Obama said. “They need relief now. So my attitude is let’s build up the system we got, let’s make it more efficient, we may be over time–as we make the system more efficient and everybody’s covered–decide that there are other ways for us to provide care more effectively.”

Actually there is nothing new here. It’s the same formulation Obama has said/used in recent years, and only a slight shading of a change from where he was earlier. But since inquiring (or is that enquiring minds want to know, here is the rest of the story:

First, it should be noted that in addition to whatever policy analysis he has done, Obama actually has something of a personal connection to knowing about single payer since (I am not breaking any confidentiality here, since it is public knowledge) the physician group that he has been going to for years for his own personal medical care includes one the most famous physician single payer (and all around progressive political) advocates, Dr. Quentin Young. Given the political activism of that physician group and the young Mr. Obama’s intests in politics and policy, one can assume it has been discussed during check-ups! Obama attended Quentin’s 80th birthday back in 2003.

Now here is a video of Obama in 2003 speaking to the Illinois State AFL-CIO on June 30, 2003, supporting Single Payer as what he would like to see:

Transcript from Obama in 2003:

“I happen to be a proponent of a single payer universal health care program.” (applause) “I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care cannot provide basic health insurance to everybody. And that’s what Jim is talking about when he says everybody in, nobody out. A single payer health care plan, a universal health care plan. And that’s what I’d like to see. But as all of you know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.” – Obama speaking to the Illinois AFL-CIO, June 30, 2003.

But here is how it gets, perhaps, slightly, revised, by now national candidate Obama in 2007, at our very own YKos meeting in Chicago, to saying the same thing as he is quoted in the Wall Street Journal as saying:

It is even on the Obama campaign fact check page, that his language (at least since going national after 2003) has been consistent:

If Obama Were Starting From Scratch, He Would Support A Single Payer System

So perhaps it is rhetorically just a smidge weaker in 2007-to-Present, compared to what he said in 2003; but really it is substantively the same. He would prefer single payer in principle, but current actual fight is limited to what he sees as what is feasible. And after that, who knows…

This is a common formulation/excuse… to acknowledge that single payer is better, but that it is politically impractical, and therefore to fight for some compromise alternative that one knows is not as good.

It is actually somewhat better then the approach/response the Clinton’s have always given which is complete and total a priori dismissal of Single Payer.

But it is still a little bit sad — to recognize what most in the health economic and health policy field acknowledge, and what independent analysts such as the GAO, the CBO and the Lewin Group have all determined that Single Payer is the only way to get to Universal coverage, Comprehensive coverage, Individual affordability, and System-wide cost control — and still shy away from actually fighting for it.

But as an advocote and wonk, I am not dependent on corporate support, nor do have some psychological investment in cheering for the (in the short run only) winning side… I choose to support the actual best plan.

How about you?

Adult children covered by parents' plans

Health coverage boon for young adults

By Ray Long and Monique Garcia
Chicago Tribune
August 19, 2008

Young adults could stay on their parents’ health insurance until they turn 26 under a new law pushed by Gov. Rod Blagojevich and approved Tuesday by the Illinois Senate.

The estimated 300,000 twentysomethings who are eligible wouldn’t have to live at home — or even in Illinois. And if they’re in the military, they could remain covered by mom and dad until they turn 30. They must stay single, however.

http://www.chicagotribune.com/news/nationworld/chi-legis-insurance-20aug20,0,6922973.story

Comment:

By Don McCanne, MD

For those who contend that comprehensive reform is not politically feasible and that reform must occur in incremental steps, this is precisely the type of legislation that they support. Young adults frequently fall through the cracks in health insurance coverage, having one of the highest rates of uninsurance. This legislation provides them with another option for health insurance and, theoretically, should reduce the total numbers of uninsured.

Should we celebrate this success of the incrementalists? Maybe, but before we do we should attempt to understand some of the other policy implications.

* Young adults with conditions such as diabetes, hypertension or HIV infection need coverage and would more likely continue in their parents’ plans – a classic example of adverse selection. Whether individual or employer-sponsored plans, allowing more high-cost adults to opt into the insurance pools will inevitably cause an increase in premiums. At a time when affordability of coverage already has become a problem, higher premiums will cause more to drop coverage.

* In small groups, adding one individual with significant chronic disease can cause premiums to skyrocket, making the plan unaffordable for the entire group.

* Even if initially in good health, young adults can develop chronic conditions while covered by their parents’ plans, which might make them uninsurable when they are no longer eligible for those plans. They would be disqualified for the low-cost plans designed for the young invincibles.

* Keeping an adult child on the plan can cause the premium to be set at a family rate rather than at the much less expensive rates for individuals or couples. A policy that expands the window of eligibility is of little value if you can’t pay for it.

* This legislation requires that the adult child remain single. Basing eligibility for insurance coverage simply on marital status can have perverse policy implications, possibly impacting the very foundation of the family.

* The primary reason that so many young adults are uninsured is because they have difficulty spending a large amount of money on health coverage when they need the money for other purposes, and it is quite unlikely that they would need much health care anyway. They would rather take their chances. Of course, as free riders, if they should ever develop major problems, they would shift their costs of care to the rest of us.

The benefits of this legislation are greater than the deficiencies, but it is such a tiny baby step, and a flawed one at that, that it cannot begin to compensate for the persistent deterioration in coverage that continues to plague us.

No celebrations today – not until we have comprehensive reform that automatically and permanently provides equitably-funded comprehensive coverage for everyone.

Adult children covered by parents’ plans

Health coverage boon for young adults

By Ray Long and Monique Garcia
Chicago Tribune
August 19, 2008

Young adults could stay on their parents’ health insurance until they turn 26 under a new law pushed by Gov. Rod Blagojevich and approved Tuesday by the Illinois Senate.

The estimated 300,000 twentysomethings who are eligible wouldn’t have to live at home — or even in Illinois. And if they’re in the military, they could remain covered by mom and dad until they turn 30. They must stay single, however.

http://www.chicagotribune.com/news/nationworld/chi-legis-insurance-20aug20,0,6922973.story

Comment:

By Don McCanne, MD

For those who contend that comprehensive reform is not politically feasible and that reform must occur in incremental steps, this is precisely the type of legislation that they support. Young adults frequently fall through the cracks in health insurance coverage, having one of the highest rates of uninsurance. This legislation provides them with another option for health insurance and, theoretically, should reduce the total numbers of uninsured.

Should we celebrate this success of the incrementalists? Maybe, but before we do we should attempt to understand some of the other policy implications.

* Young adults with conditions such as diabetes, hypertension or HIV infection need coverage and would more likely continue in their parents’ plans – a classic example of adverse selection. Whether individual or employer-sponsored plans, allowing more high-cost adults to opt into the insurance pools will inevitably cause an increase in premiums. At a time when affordability of coverage already has become a problem, higher premiums will cause more to drop coverage.

* In small groups, adding one individual with significant chronic disease can cause premiums to skyrocket, making the plan unaffordable for the entire group.

* Even if initially in good health, young adults can develop chronic conditions while covered by their parents’ plans, which might make them uninsurable when they are no longer eligible for those plans. They would be disqualified for the low-cost plans designed for the young invincibles.

* Keeping an adult child on the plan can cause the premium to be set at a family rate rather than at the much less expensive rates for individuals or couples. A policy that expands the window of eligibility is of little value if you can’t pay for it.

* This legislation requires that the adult child remain single. Basing eligibility for insurance coverage simply on marital status can have perverse policy implications, possibly impacting the very foundation of the family.

* The primary reason that so many young adults are uninsured is because they have difficulty spending a large amount of money on health coverage when they need the money for other purposes, and it is quite unlikely that they would need much health care anyway. They would rather take their chances. Of course, as free riders, if they should ever develop major problems, they would shift their costs of care to the rest of us.

The benefits of this legislation are greater than the deficiencies, but it is such a tiny baby step, and a flawed one at that, that it cannot begin to compensate for the persistent deterioration in coverage that continues to plague us.

No celebrations today – not until we have comprehensive reform that automatically and permanently provides equitably-funded comprehensive coverage for everyone.

What Do MoveOn Members Think About Health Care? Who Knows? A Reply to MoveOn’s Eli Pariser

By Miles Mogulescu
The Huffington Post
Posted August 15, 2008

On Wednesday I posted a blog on Huffington Post asking readers to sign a Petition requesting that our friends at MoveOn.Org let its members vote on whether they support universal single payer health care or reforming private health insurance (while adding an optional public plan that the uninsured could purchase themselves). In less than 48 hours, nearly 3,000 people have signed the Petition and, as the Petition spreads virally, new signatures keep coming in at the rate of 50-100 per hour.

On Thursday, Eli Pariser of MoveOn responded with a blog asserting that MoveOn had already determined that by 70%-23%, a majority of its members supported reforming private health insurance with an optional public alternative instead of supporting universal single payer health care, based upon what MoveOn claimed was a “random sample” of its members.

At first this seemed strange to me. Most members of MoveOn are presumably progressive. So one would tend to assume that they would be more supportive of single payer health care than the average American voter. But while polls by major news organizations have shown a majority of Americans supporting single payer, MoveOn’s “random sample” indicated MoveOn’s member’s rejected single payer by nearly 3-1 in favor of a private insurance/public hybrid.

Meanwhile, an Associated Press poll in December, 2007 asked voters “Do you consider yourself a supporter of a single-payer health care system that is a national plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?” 54% said “Yes” and 44% said “No”.

A CBS News poll last September asked “Which do you think would be better for the country: having one health insurance program covering all Americans that would be administered by the government and paid for by the taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?” 55% chose “One Program for All” and only 29% chose “The Current system”.

Something seemed strange here. Could it really be that average American voter is more progressive on universal health care than the average MoveOn member?

Then I started to look more closely at MoveOn’s “random sample” and it started to raise a lot of questions about whether it really gave an accurate reading of the opinions of MoveOn’s members.

Was this survey conducted by a professional polling organization or put together by the MoveOn staff? Will MoveOn post the polling methodology and statistical results? How many people were sampled and how were they selected? I’m not an expert on statistics, but here are some questions that one Doctor posed about the survey: “What is the power of the study, the standard deviation, the p number?” I’ve emailed these questions to my friends on the MoveOn staff, but they haven’t responded yet. I look forward to their responses, either in private or here in the Huffington Post.

Most important, “Was there any validation study done beforehand to assess the wording of the questions?” The closer I looked, the more it appeared as though the wording of the MoveOn survey had a build in bias that at least appears to skew it towards eliciting the answers that the MoveOn and Health Care For American Now staff had already decided that they agreed with. Two alternatives were provided:

* “Support single payer: Work to cover all Americans by switching from their existing health coverage to free Medicare-style national health insurance and abolishing private insurance companies from our health care system.”
* “Support national public health insurance: Work to cover all Americans by offering everyone the choice to switch from their existing health coverage to free or affordable Medicare-style national health insurance, but don’t require people to switch.”

This wording is confusing. It makes it appear as though the issue is about free choice: Either you can be forced by the Feds to switch into a government program or be given the free choice to keep your present insurance or switch into a “free or affordable” Medicare-style program. I’m a strong supporter of single payer, but if you phrase the issue as one of individual free choice of whether to switch or not, I’d choose the free choice alternative, too.

There are so many ways in which, in real life, the second “appealing” free choice is a fictional alternative. It is unlikely that voluntary “Medicare-style national health insurance” would be “free or affordable” for most middle class Americans. The plan that MoveOn and HCAN is actually backing is based on the Health Care for America plan developed by Jacob Hacker and the Campaign for America’s Future. According to the financial model for this, plan prepared for the plan’s backers by the Lewin Group, the real cost for a two-parent family is $8040 a year. In addition, families could have to pay as much as $5,000 per year in out of pocket costs. Moreover, the Lewin Group’s cost projections are probably low, because they assume that 128.6 million Americans would be insured by the optional public plan, a wildly inflated number that would give the public plan bargaining power to reduce costs that it is unlikely to have. A 2007 study by the Brookings Institution estimates that the annual cost for a family of four to buy a Medicare-type plan would be $10,000 per year. Whether the number is $8,000 a year or $10,000 a year, plus co-payments, this is hardly ‘free or cheap” except for those close enough to the poverty line to receive a substantial government subsidy.

Meanwhile, for this plan to have even a chance to work as advertised, it would require a government mandate requiring everyone not covered by their employer to buy insurance. For middle class people who are not poor enough to receive a substantial government subsidy, this would be a financial backbreaker, making this plan a dead bang political loser.

Finally, MoveOn and HCAN argue that an optional public alternative would somehow provide a transition to single payer. They believe it would be so much more attractive than private insurance that more and more people would buy it until private insurance is marginalized. In fact, the opposite is true. Even given administrative savings, as a cadillac insurance program with good benefits, coverage for all medically necessary conditions, choice of doctors, and low deductibles and co-pays, it would be an expensive program. Private insurers would compete by offering low-cost stripped down programs with limited benefits and high deductibles and co-pays, but which would siphon off most of the young and healthy. The public program would become the private insurers’ dumping ground for older and less healthy people whom they don’t want to cover anyway, thus making the public program increasingly expensive. (This is known as “adverse selection”.) Far from marginalizing private insurance, this plan is likely to make the public program increasingly unaffordable for most Americans and bust the federal budget by increasing the cost of federal subsidies.

So the MoveOn “random sample” question alternative for an optional “free or affordable Medicare-style program” is not based on reality. That would explain why MoveOn’s “random sample” makes it appear that MoveOn’s members are to the right of the American public on single payer.

I truly wish there could be an easy solution that would provide good inexpensive health care for all Americans and wouldn’t involve a major political battle with the health insurance and big pharma lobbies. In his Huffpo blog, Pariser accurately warns against “the huge campaign we’ll face from private insurance companies, HMOs, and pharmaceutical companies.” He then argues that the MoveOn/HCAN proposes “the best strategy for progressives to take” because presumably it will face less political opposition from the special interests. In another Huffpo blog, HCANs Richard Kirsch even argues that the insurance lobby has “nothing to fear” from HCAN’s plan, since under HCAN’s principles, “people are free to keep their health insurance if they want. They can choose another private plan if they prefer”.

MoveOn/HCAN honestly believes that single payer supporters are politically naive, and that MoveOn/HCAN can pass a plan that provides tough new regulations on the private insurance industry, limits their profits, and offers a public plan that will seriously compete with private insurance, without the insurance lobby fighting against such a plan as hard as they will fight against single payer. Doesn’t that sound a bit naive?

So, if to have a chance of passing meaningful universal health care reform, we’re going to have to build a mass movement to take on the full force of the insurance and pharma lobbies anyway, why, as George Lakoff puts it, does MoveOn/HCAN want to “surrender in advance” by conceding on single payer and promising the continuation of wasteful private insurance system? Somewhere along the line it may be necessary to make some pragmatic political compromises. But you don’t win a political fight by giving up your most important principles before the fight even begins. In particular, the job of a progressive mass movement like MoveOn is not to pre-negotiate in advance with the insurance lobby, but to help organize a mass citizens’ movement to take it on.

I hope our friends at MoveOn will allow all of its 3.2 million members to vote, in a fairly worded professional poll, on which direction MoveOn should take in the fight for universal health care, after a full and fair debate on the issue is presented to its members.

If you agree, please sign the Petition.

Shattuck Lecture on coverage for all Americans

Health of the Nation -- Coverage for All Americans

Charles D. Baker, Arthur Caplan, Ph.D., Karen Davis, Ph.D., Susan Dentzer, Arnold M. Epstein, M.D., Bill Frist, M.D., Robert S. Galvin, M.D., Ruben J. King-Shaw, Jr., Thomas H. Lee, M.D., Jonathan B. Oberlander, Ph.D., Sara Rosenbaum, J.D., Steven A. Schroeder, M.D., and Reed V. Tuckson, M.D., moderated by Arthur R. Miller, J.D.
The New England Journal of Medicine
August 21, 2008
Shattuck Lecture

Sara Rosenbaum: [Access to care is] the most basic ethical issue of all. But it is a national decision on our part. It’s not the federal decision; it’s not the state decision; it is a national social decision. And we’ve been very bad about this.

Steven Schroeder: I think that a country should be judged by how it treats its less fortunate. In that respect, I’m ashamed of our country.

Jonathan Oberlander: If there’s one lesson that we’ve learned about health reform in the last few decades, [it’s that] being right doesn’t count for very much. We can come up with lots of stories to evoke moral outrage. And it’s not just about the uninsured. There are many Americans with insurance who have inadequate protection and who file for bankruptcy every year because they’re underinsured. But if we’re going to fight this battle for health reform on moral grounds, we’re going to lose.

Jonathan Oberlander: The price tag for universal coverage really is not that much. If you talk about adding the uninsured to the existing system, you’re talking about roughly $100 billion a year. We already spend over $2 trillion, so it’s a mark-up but not much. When we cut taxes in 2001 and 2003, we found the money to do that. When we passed the Medicare Prescription Drug Benefit in 2003, we found the money to do that. When we went to war in Iraq, we found the money to do that. So this is a question of priorities. And the uninsured are not a political priority.

http://www.nejm.org/perspective/health%2Dof%2Dthe%2Dnation%2Dvideo/

Comment:

By Don McCanne, MD

It would be worth your time to either watch the video or read the transcript of this very unusual Shattuck Lecture. For one hour Arthur Miller prods this panel on a discussion of important challenges to the American health care system. Comments are invited at the link above.

You likely will be disappointed, but that is precisely why you should at least skim over the transcript. It is disconcerting to see how ineffective a select panel of noted experts can be in framing the problems, much less in approaching any real solutions. Some exceptions are represented by the individuals quoted above.

We can do it – easily. But will we? If the ethics won’t drive us, what will?

(Hint: money. Establishing a value-based single payer system that takes care of everyone would cost less than passively accepting a continuing intolerable increase in health care costs in a system that leaves so many out. We need to target those who pay the bills.)

What Do MoveOn Members Think About Health Care? Who Knows? A Reply to MoveOn's Eli Pariser

By Miles Mogulescu
The Huffington Post
Posted August 15, 2008

On Wednesday I posted a blog on Huffington Post asking readers to sign a Petition requesting that our friends at MoveOn.Org let its members vote on whether they support universal single payer health care or reforming private health insurance (while adding an optional public plan that the uninsured could purchase themselves). In less than 48 hours, nearly 3,000 people have signed the Petition and, as the Petition spreads virally, new signatures keep coming in at the rate of 50-100 per hour.

On Thursday, Eli Pariser of MoveOn responded with a blog asserting that MoveOn had already determined that by 70%-23%, a majority of its members supported reforming private health insurance with an optional public alternative instead of supporting universal single payer health care, based upon what MoveOn claimed was a “random sample” of its members.

At first this seemed strange to me. Most members of MoveOn are presumably progressive. So one would tend to assume that they would be more supportive of single payer health care than the average American voter. But while polls by major news organizations have shown a majority of Americans supporting single payer, MoveOn’s “random sample” indicated MoveOn’s member’s rejected single payer by nearly 3-1 in favor of a private insurance/public hybrid.

Meanwhile, an Associated Press poll in December, 2007 asked voters “Do you consider yourself a supporter of a single-payer health care system that is a national plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?” 54% said “Yes” and 44% said “No”.

A CBS News poll last September asked “Which do you think would be better for the country: having one health insurance program covering all Americans that would be administered by the government and paid for by the taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?” 55% chose “One Program for All” and only 29% chose “The Current system”.

Something seemed strange here. Could it really be that average American voter is more progressive on universal health care than the average MoveOn member?

Then I started to look more closely at MoveOn’s “random sample” and it started to raise a lot of questions about whether it really gave an accurate reading of the opinions of MoveOn’s members.

Was this survey conducted by a professional polling organization or put together by the MoveOn staff? Will MoveOn post the polling methodology and statistical results? How many people were sampled and how were they selected? I’m not an expert on statistics, but here are some questions that one Doctor posed about the survey: “What is the power of the study, the standard deviation, the p number?” I’ve emailed these questions to my friends on the MoveOn staff, but they haven’t responded yet. I look forward to their responses, either in private or here in the Huffington Post.

Most important, “Was there any validation study done beforehand to assess the wording of the questions?” The closer I looked, the more it appeared as though the wording of the MoveOn survey had a build in bias that at least appears to skew it towards eliciting the answers that the MoveOn and Health Care For American Now staff had already decided that they agreed with. Two alternatives were provided:

* “Support single payer: Work to cover all Americans by switching from their existing health coverage to free Medicare-style national health insurance and abolishing private insurance companies from our health care system.”
* “Support national public health insurance: Work to cover all Americans by offering everyone the choice to switch from their existing health coverage to free or affordable Medicare-style national health insurance, but don’t require people to switch.”

This wording is confusing. It makes it appear as though the issue is about free choice: Either you can be forced by the Feds to switch into a government program or be given the free choice to keep your present insurance or switch into a “free or affordable” Medicare-style program. I’m a strong supporter of single payer, but if you phrase the issue as one of individual free choice of whether to switch or not, I’d choose the free choice alternative, too.

There are so many ways in which, in real life, the second “appealing” free choice is a fictional alternative. It is unlikely that voluntary “Medicare-style national health insurance” would be “free or affordable” for most middle class Americans. The plan that MoveOn and HCAN is actually backing is based on the Health Care for America plan developed by Jacob Hacker and the Campaign for America’s Future. According to the financial model for this, plan prepared for the plan’s backers by the Lewin Group, the real cost for a two-parent family is $8040 a year. In addition, families could have to pay as much as $5,000 per year in out of pocket costs. Moreover, the Lewin Group’s cost projections are probably low, because they assume that 128.6 million Americans would be insured by the optional public plan, a wildly inflated number that would give the public plan bargaining power to reduce costs that it is unlikely to have. A 2007 study by the Brookings Institution estimates that the annual cost for a family of four to buy a Medicare-type plan would be $10,000 per year. Whether the number is $8,000 a year or $10,000 a year, plus co-payments, this is hardly ‘free or cheap” except for those close enough to the poverty line to receive a substantial government subsidy.

Meanwhile, for this plan to have even a chance to work as advertised, it would require a government mandate requiring everyone not covered by their employer to buy insurance. For middle class people who are not poor enough to receive a substantial government subsidy, this would be a financial backbreaker, making this plan a dead bang political loser.

Finally, MoveOn and HCAN argue that an optional public alternative would somehow provide a transition to single payer. They believe it would be so much more attractive than private insurance that more and more people would buy it until private insurance is marginalized. In fact, the opposite is true. Even given administrative savings, as a cadillac insurance program with good benefits, coverage for all medically necessary conditions, choice of doctors, and low deductibles and co-pays, it would be an expensive program. Private insurers would compete by offering low-cost stripped down programs with limited benefits and high deductibles and co-pays, but which would siphon off most of the young and healthy. The public program would become the private insurers’ dumping ground for older and less healthy people whom they don’t want to cover anyway, thus making the public program increasingly expensive. (This is known as “adverse selection”.) Far from marginalizing private insurance, this plan is likely to make the public program increasingly unaffordable for most Americans and bust the federal budget by increasing the cost of federal subsidies.

So the MoveOn “random sample” question alternative for an optional “free or affordable Medicare-style program” is not based on reality. That would explain why MoveOn’s “random sample” makes it appear that MoveOn’s members are to the right of the American public on single payer.

I truly wish there could be an easy solution that would provide good inexpensive health care for all Americans and wouldn’t involve a major political battle with the health insurance and big pharma lobbies. In his Huffpo blog, Pariser accurately warns against “the huge campaign we’ll face from private insurance companies, HMOs, and pharmaceutical companies.” He then argues that the MoveOn/HCAN proposes “the best strategy for progressives to take” because presumably it will face less political opposition from the special interests. In another Huffpo blog, HCANs Richard Kirsch even argues that the insurance lobby has “nothing to fear” from HCAN’s plan, since under HCAN’s principles, “people are free to keep their health insurance if they want. They can choose another private plan if they prefer”.

MoveOn/HCAN honestly believes that single payer supporters are politically naive, and that MoveOn/HCAN can pass a plan that provides tough new regulations on the private insurance industry, limits their profits, and offers a public plan that will seriously compete with private insurance, without the insurance lobby fighting against such a plan as hard as they will fight against single payer. Doesn’t that sound a bit naive?

So, if to have a chance of passing meaningful universal health care reform, we’re going to have to build a mass movement to take on the full force of the insurance and pharma lobbies anyway, why, as George Lakoff puts it, does MoveOn/HCAN want to “surrender in advance” by conceding on single payer and promising the continuation of wasteful private insurance system? Somewhere along the line it may be necessary to make some pragmatic political compromises. But you don’t win a political fight by giving up your most important principles before the fight even begins. In particular, the job of a progressive mass movement like MoveOn is not to pre-negotiate in advance with the insurance lobby, but to help organize a mass citizens’ movement to take it on.

I hope our friends at MoveOn will allow all of its 3.2 million members to vote, in a fairly worded professional poll, on which direction MoveOn should take in the fight for universal health care, after a full and fair debate on the issue is presented to its members.

If you agree, please sign the Petition.

Insurance falls as medical bills rise

Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families

By Sara R. Collins, Ph.D., Jennifer L. Kriss, Michelle M. Doty, Ph.D., and Sheila D. Rustgi
The Commonwealth Fund
August 20, 2008

Using data from four years of the Commonwealth Fund Biennial Health Insurance Survey, this report examines the status of health insurance for U.S. adults under age 65 and the implications for family finances and access to health care. Insurance coverage deteriorated over the past six years, with declines in coverage most severe for moderate-income families. As result, more families are experiencing medical bill problems or cost-related delays in getting needed care. In 2007, nearly two-thirds of U.S. adults, or an estimated 116 million people, struggled to pay medical bills, went without needed care because of cost, were uninsured for a time, or were underinsured (i.e., were insured but not adequately protected from high medical expenses).

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=700872

And…

Seeing Red: The Growing Burden of Medical Bills and Debt Faced by U.S. Families

By Michelle M. Doty, Ph.D., Sara R. Collins, Ph.D., Sheila D. Rustgi, and Jennifer L. Kriss
The Commonwealth Fund
August 20, 2008

Analysis of the 2007 Commonwealth Fund Biennial Health Insurance Survey finds the proportion of working-age Americans who struggled to pay medical bills and accumulated medical debt climbed from 34 percent to 41 percent, or 72 million people, between 2005 and 2007. In addition, 7 million adults age 65 and older had these problems, bringing the total to 79 million adults with medical debt or bill problems. All income groups reported an increase. Families with low or moderate incomes were particularly hard hit, as were adults who had gaps in health coverage or those underinsured. Because of medical bills or accumulated medical debt, an estimated 28 million adults reported they used up all their savings, 21 million incurred large credit card debt, and another 21 million were unable to pay for basic necessities. Sixty-one percent of those with medical debt or bill problems were insured at the time care was provided.

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=700868

Comment:

By Don McCanne, MD

How well is our health care financing system working? Two-thirds of adults under 65 have problems with their health insurance and paying for health care. Forty-one percent have medical bill problems or are paying off medical debt, even though sixty-one percent of these individuals were insured at the time care was provided.

So what is the response of the politicians to this health care financing crisis? Sen. John McCain says that we should allow insurers to sell us more affordable plans (even though that means that the stripped-down plans would not provide adequate financial protection in the face of medical need). Sen. Barack Obama says that we should authorize only plans with adequate benefits, whether public or private plans (even though that means that even more of us would be unable to afford to purchase the plans). Sen. Max Baucus, Chair of the Senate Finance Committee which must clear all health care financing legislation, says that comprehensive reform is not feasible and that we must proceed with smaller incremental steps, beginning with expanding the children’s health insurance program, and tweaking Medicare.

Wouldn’t you think that the politicians would be interested in reform that would allow us to continue to fund the most expensive health care system of all, without the necessity of exposing individuals to financial hardship merely because they need health care?

I was interviewed by a Canadian journalist this week. He said that the Canadians could not understand how we could spend so much money on our health care system and yet leave so many without adequate protection against financial losses for health care. They think that there is something very fundamentally wrong with our health care financing system that can be fixed. If only we could get our politicians to acknowledge that there is a solution that would actually work: a single payer national health program.

Will the real Harry and Louise please stand up

www.harryandlouisereturn.com
August 20, 2008

Scene: In the kitchen, at the breakfast table

Harry: Health care costs are up again. Small companies are being forced to cut their plans.

Louise: Tell me about it. You know, Lisa’s husband just found out he has cancer.

Harry: But he’s covered. Right?

Louise: No. He just joined a start-up, and he can’t afford a plan.

Harry: Too many people are falling through the cracks.

Louise: Whoever the next president is, health care should be at the top of his agenda. Bring everyone to the table, and make it happen.

(This ad campaign is sponsored by the American Cancer Society Cancer Action Network (ACS CAN), the American Hospital Association (AHA), the Catholic Health Association (CHA), Families USA, and the National Federation of Independent Business (NFIB).)

2008 Harry and Louise ad:
http://harryandlouisereturn.com/

1994 Harry and Louise ad:
http://www.youtube.com/watch?v=Dt31nhleeCg&NR=1

Comment:

By Don McCanne, MD

What a refreshing change. In fourteen years, Harry and Louise’s breakfast table conversation has changed from, “If we let the government choose, we lose,” to “Bring everyone to the table and make it happen.” But what does this mean?

At today’s press conference inaugurating this ad campaign, it was clear from the diverse groups involved that the message is that we must all join together to make reform happen. But before the press conference was even over, red flags were raised.

Most disconcerting was the fact that AHIP’s Karen Ignagni was invited to express the support of the private insurance industry in this effort, even though AHIP is not a sponsor of this campaign. During the Q&A, she indicated that AHIP was prepared to support its specific proposal for reform (a model that uses private plans to insure the low-cost healthy, while shifting those with higher-cost needs to taxpayer-funded programs).

When Teddy Davis of ABC News asked about the problem of guaranteed issue without a mandate, Ron Pollack (Families USA) responded, “I don’t think that we’re prepared to answer hypothetical questions.” But really, are crucial fundamental policy issues to be dismissed as mere hypotheticals?

Sadly, this is merely another chapter in the saga of the strange bedfellow coalitions. The policy opinions supported by the participants are mutually incompatible and can only lead to a result that Ron Pollack has described repeatedly: everyone walks away, supporting their second favorite choice – the status quo (even though no one actually supports the status quo). This process is yet another recipe for political inertia.

There are some very fundamental principles which should garner broad support if we are truly serious about reform.

Costs must be contained. Projections that health care will soon consume maybe half of our GDP are totally unrealistic. Essential spending in other sectors of our economy will create a barrier beyond which no further funds would be available for health care. Tragically, the uninsured and under-insured have already crashed into that solid wall, and that includes many middle-income Americans. Cost increases will only move that barrier in front of more and more of us.

There are two fundamental approaches to controlling costs. We can withhold essential health care from people who cannot afford it, an option for the heartless, or we can demand a reduction in wasteful spending such as our profound administrative excesses and our non-beneficial high-tech services. The market has been and always will be incapable of controlling these costs since markets function to sell us more, not fewer, products and services. A monopsony operating in the public interest will be required to bring us greater value and affordability in our health care purchasing, and that can be accomplished only by enacting enabling government policies.

We can no longer accept the suffering and death that occurs amongst us merely because many individuals don’t have the resources to pay for care. Everyone must be included under the umbrella of a comprehensive financing system.

Since average-income individuals can no longer afford their pro rata share of health care financing, a transfer must be enabled through progressive tax policies. Rejection of this fundamental principle would equate with the tacit acceptance for too many of us of financial hardship and bankruptcy as a consequence of ill health.

Louise is right. We need to bring everyone to the table. That includes everyone who needs health care or may need it at some time in the future. That is everyone. Everyone.

Libertarian ideologues and moneygrubbers stand aside. Make room for the people.