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qotd: National health insurance makes the green journal

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qotd: National health insurance makes the green journal

National Health Insurance: Could It Work in the US?

By James E. Dalen, MD, MPH, Joseph S. Alpert, MD
The American Journal of Medicine
July 2008

National health insurance covers the entire population of many European countries at a much lower cost than US health care. Could such a system of national health insurance work in the US? We already have such a system — it is called Medicare, and it has worked very well for more than 40 years! Medicare pays the private sector to deliver quality health care to more than 44 million Americans. Those who stick with traditional Medicare have free choice of physicians and hospitals. Nearly every US physician and nearly every hospital in the US has elected to participate in Medicare.

In a 2003 Pew poll, 67% favored government guaranteed national health insurance even if meant higher taxes, and a 2007 New York Times/CBS poll reported that 64% stated that the Federal government should guarantee health insurance for all Americans. Maybe the American people are ahead of their legislators!

http://download.journals.elsevierhealth.com/pdfs/journals/0002-9343/PIIS0002934308002465.pdf

Comment:

By Don McCanne, MD

Reading a message in support of a Medicare-like national health insurance program is certainly not a new experience for single payer advocates. What is astonishing is that this was published in “the green journal,” The American Journal of Medicine, one of the most prestigious medical publications in this nation. Furthermore, it was coauthored by the Editor-in-Chief, Joseph Alpert.

National health insurance is no longer a fringe concept. The American people have made it mainstream. It has become an imperative. We now need to elect legislators who understand that.

National Health Insurance: Could It Work in the US?

COMMENTARY
The American Journal of Medicine

The US health care system, which depends on private, for-profit health insurance, is not working. It is time for national health insurance!1,2

One would expect that the US, with its well educated population; high standard of living; well trained physicians, nurses, and other health professionals; and well equipped hospitals and diagnostic facilities would provide optimalcare to all its citizens.

A further reason why Americans should expect optimal health care is that the US spends much more for health care than any other country. We pay about twice as much as other countries. In 2005, the per capita health care expense was $6401 for Americans, compared to an average of $3114 in 30 industrial nations in the Organization for Economic Co-operation and Development.3 And, our health care costs keep escalating faster than the rate of inflation.4

We pay more; but we get less for our money! We do not have the world’s best health care. The World Health Organization ranked the US health care system the 37th best of 191 countries, and last among 17 industrialized countries in 2000.5 Our health outcomes: life expectancy, infant mortality, and immunization rates are well behind other industrialized nations.3 In a 2000 survey, 60% of our citizens said that they were dissatisfied with their health care.5

The major reason that our health outcomes are poor is that more than 46 million Americans have limited access to care because they don’t have health insurance.6 Millions of others have inadequate access because they have inadequate insurance. A New York Times/CBS poll in 2007 found that 28% of Americans were without health insurance at some time in 2007, and 61% who were uninsured did not obtain needed care.7

Even though we spend more on health care than any other country, we are the only industrialized country that does not ensure access to health care to all its citizens. The primary source of health insurance in the US is employment-based private (for-profit) insurance which covers 61% of the non-elderly population.6 However, the number covered by employment-based insurance is decreasing8 because some employers, especially small employers, can not afford to provide insurance. The cost of health insurance continues to exceed the rate of inflation. From 2002 until 2007 the cost increased by 78% while the inflation rate increased by 17%.9 As the cost increases some employers stop providing health insurance, or provide insurance with fewer benefits and higher co-pays. Others shift a larger percent of the premium to their employees forcing some employees to drop their health insurance.

More than half of the uninsured are employed, or the dependents of employed persons.6 They lack insurance because their employer doesn’t provide it, and they can’t afford private health insurance. Private health insurance for a family can cost more than $12,000 per year.8 For many older Americans, and for those with “prior conditions” (ie, any known health problem!), the cost of insurance, if it is available, can be out of reach.

Given the high cost of health care, very, very few Americans can afford to pay for health care out of pocket. As a result, Americans without health insurance receive less primary and preventive care and have poorer health outcomes. The bottom line is that the mortality rate for the uninsured is higher than for the insured.10

Our fragmented system of health care, with thousands of health insurance providers, has enormous administrative costs, and for some providers, enormous profits. Only about two-thirds of private health insurance premiums are spent on health care; the rest goes to administrative costs, costs of billing, and profits for the insurance company.11 The overhead in our health care system is more than twice that of countries with a single payer. Administrative costs account for 31% of all health care expenditures in the US, but only 17% in Canada’s single payer health care system.12

In addition, we pay more than twice what other countries do for prescription drugs,13 because, unlike most of the rest of the world, we have no controls on the price of prescription drugs. The Medicare Modernization Act legislation forbids Medicare from negotiating prices with drug companies.14 Many Americans with chronic conditions can’t afford the prescription drugs that can prevent strokes and heart attacks and other conditions leading to death or hospitalization. Multiple studies have shown that many Americans fail to fill or renew prescriptions, or take fewer doses than prescribed because of the costs.15,16

The combination of the excess administrative costs, excess profits, and the excess cost of prescription drugs in the US health care system greatly exceeds what it would cost to provide health care to all uninsured Americans.17 We can decrease health care costs and provide health care to all Americans by adopting mandatory national, non-profit health insurance. The insurance could be financed by a payroll tax shared by the employee and the employer. Premiums would be community-based; that is, they would not be dependent on age or medical history. Patients would have free choice of physicians who would be paid fee-for-service, and have free choice of hospitals and other health care providers.

National health insurance covers the entire population of many European countries at a much lower cost than US health care.18-20 Could such a system of national health insurance work in the US? We already have such a system–it is called Medicare, and it has worked very well for more than 40 years! Medicare pays the private sector to deliver quality health care to more than 44 million Americans. Those who stick with traditional Medicare have free choice of physicians and hospitals. Nearly every US physician and nearly every hospital in the US has elected to participate in Medicare. The administrative costs of Medicare are only 2%21 compared with 12% with for-profit health insurers.12

In a 2003 Pew poll, 67% favored government guaranteed national health insurance even if meant higher taxes,22 and a 2007 New York Times/CBS poll reported that 64% stated that the Federal government should guarantee health insurance for all Americans.7 Maybe the American people are ahead of their legislators!

Why not Medicare for all Americans? It works!

James E. Dalen, MD, MPH
Professor Emeritus of Medicine and Public Health
University of Arizona

Joseph S. Alpert, MD
Professor of Medicine
University of Arizona College of Medicine
Editor-in-Chief, The American Journal of Medicine

References

1. Dalen JE. Health care in America; the good, the bad, and the ugly. Arch Intern Med. 2000;60:2573-2576.
2. Alpert JS. Medical refugees in America. Arch Intern Med. 2000;160: 417-418.
3. Organisation for Economic Co-operation and Development. OECD Health Data, 2007.
4. Catlin A, Cowan C, Heffler S, et al. National health spending in 2005: the slowdown continues. Health Aff. 2007;26:142-153.
5. Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on health system performance. Health Aff. 2001;20: 10-20.
6. Henry J. Kaiser Foundation. Health insurance coverage in America. 2006 data update. October, 2007. Available at: http://www.kff.org/uninsured/upload/7451-03.pdf. Accessed June 10, 2008.
7. Toner R, Elder J, Thee M, et al. Most support U.S. guarantee of health care. The New York Times March 2, 2007.
8. Henry J. Kaiser Family Foundation. Survey of Employer Health Benefits 2007. September 11, 2006. Available at: http://www.kff.org/insurance/7672upload7693pdf. Accessed February 11, 2008.
9. Kaiser Family Foundation. Trends in Health Care Costs and Spending. September 2007. Available at: http://www.kff.org/insurance/upload/7692pdf. Accessed February 11, 2008.
10. Muennig P, Franks P, Gold M. The cost effectiveness of health insurance. Am J Prev Med. 2005;28:59-64.
11. Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff. 2005;24:1629-1639.
12. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003; 349:768-775.
13. Anderson GF, Shea DG, Hussey PS, et al. Doughnut holes and price controls. Health Aff. 2004;W4:396-404.
14. Dalen JE, Hartz DJ. Medicare prescription drug coverage: a very long wait for a very modest benefit. Arch Intern Med. 2005;18:325-329.
15. Rector TS, Venus PJ. Do drug benefits help Medicare beneficiaries afford prescribed drugs? Health Aff. 2004;23:213-222.
16. Tseng CW, Brook RH, Keeler E, et al. Cost-lowering strategies used by Medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage. JAMA. 2004;292:952-960.
17. Himmelstein DU, Woolhandler S. National health insurance or incremental reform: aim high, or at our feet? Am J Public Health. 2003; 93:102-105.
18. Rodwin VG. The health care system under French national health insurance: lessons for health reform in the United States. Am J Public Health. 2003;93:31-37.
19. Reinhardt UE. “Mangled competition” and “managed whatever.” Health Aff. 1999;18:92-94.
20. Christiansen T. A SWOT analysis of the organization and financing of the Danish health care system. Health Policy. 2002;59:99-106.
21. Wilensky GR, Newhouse JP. Medicare: what’s right? what’s wrong? what’s next? Health Aff. 1999;18:92-107.
22. The Pew Research Center. Bush approval slips-fix economy, say voters. August, 2003.

Uwe Reinhardt on the Dutch system

Americans down on the U.S. health-care system

By Kristen Gerencher
MarketWatch
July 13, 2008

Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University.

“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”

Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.

The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.

“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”

http://www.marketwatch.com/news/story/vital-signs-americans-rate-us/story.aspx?guid=%7B86F29D04-FC2D-466F-ADF6-2435468CE406%7D&dist=hpts

Comment:

By Don McCanne, MD

The United States currently has a private insurance system that has proven to be quite inadequate in ensuring that all of us receive the health care that we need. Some single out the new Dutch system as a model demonstrating that private plans could work for us if we merely improve the insurance markets and provide a competing public insurance option.

As Professor Reinhardt states, the Dutch system is not even vaguely close to the U.S. system, but rather is a social insurance system in disguise. Merely expanding our private plans to cover more people would not in any way emulate the Dutch system.

Some claim that a single payer system is not politically feasible because it would be too disruptive to our existing health care financing system. Yet they concede that the private insurance industry would have to undergo a massive transformation to eliminate the profound inefficiencies, inadequacies and inequities in our current system. Tight regulation of a totally transformed private insurance industry would certainly be disruptive to these players in our current financing system.

Is disruption really all that bad? The technology industry advances and thrives on innovative disruptions. New, improved, lower-cost technology replaces older, less effective, and more expensive technology. New technology is certainly disruptive to the establishment, but we shed few tears for those older companies that are no longer relevant and are replaced by newer firms.

Our current private insurance industry is functioning so poorly that, at a minimum, it requires wholesale disruption by being transformed into a highly-regulated program of social insurance. But then why should we try to revive an obsolete, last-century system of health care financing when a modern, single payer national health program would be so much more efficient?

Isn’t single payer precisely the disruptive innovation that we now need? And really, who would shed tears over the demise of the private insurers as we know them?

A system 'in the process of collapse'

By Jeoffry B. Gordon
The San Diego Union-Tribune
July 13, 2008

As a family doctor who has practiced in San Diego for more than 25 years, my daily, intimate experience of providing medical care leads me to strongly dissent from Grace-Marie Turner’s views in “How good is our health care system?” (Opinion, June 30).

Daily I see patients without health insurance who have avoided care, omitted pharmaceuticals they could not afford, or had to use emergency rooms at times of true need and incurred extraordinarily huge charges. Every two or three months I see a patient literally at death’s door due to illness previously unexamined due to financial fears.

Turner does not discuss the fact that bills due to the costs of illnesses are the largest cause of personal bankruptcies in the United States. She omits any discussion of the 47 million uninsured citizens (5 million citizens and 2 million noncitizens in California) cast aside by our “good” health care system to fend as they may.

As a case in point, it is important to note that the American Cancer Society has devoted its annual campaign this year to promoting universal access to medical care. It has determined that being poor or uninsured markedly impairs outcomes of cancer patients, and that making improvements in organizing and financing medical services would save more lives than promoting any scientific or technical innovations in the practice of oncology.

Turner omits any reference to the fact that administrative overhead and profits consume between 20 and 30 percent of health care insurance premium dollars, diverting much of these resources from the provision of health services to enrollees. The total value of money not spent on health services by health insurance companies in the United States approaches $400 billion a year — an amount that approximates the total budget of the Pentagon in 2007 (omitting supplemental appropriations for the Iraq war).

Furthermore, in my own practice I must devote about 5 percent of my time and 25 per cent of my staff time to dealing with the extraordinary complexities of multiple insurance companies and their rules. These are additional resources diverted away from patient care.

Evidently, Turner advocates for a “free-market” approach to medical care. Turning the provision of medical care from a profession into a commercial business has also had a huge impact in distorting the system of health care resources.

There is a huge deficit in (less well paid) general internists, geriatricians and family doctors; there is a surplus of fancy (and expensive) MRIs and PET scanners, etc; public health and sanitation are underfunded (see the current epidemic of tomato-born diarrhea); all resources are scarce in rural areas, and so on. These considerations demonstrate economic as well as production inefficiencies that no “business” would or could tolerate except under cartel conditions when consumers are weak and extraordinary profits can be made.

Frankly, I think the private personal health insurance system is in the process of collapse. Limitations of benefits and cost-sharing (premiums, coinsurance and deductibles) to limit care and improve profit are becoming so onerous that both businesses and individual families are going without, and an extraordinary bureaucracy is smothering health care providers.

The universal tax-financed health insurances we have for people over 65 (Medicare) and veterans and military (Tricare) are both more economically efficient and user-and provider-friendly. In my opinion, a Medicare-for-All program or single-payer health system (such as envisioned in California Senate Bill 840) would provide a tremendous advance in economic efficiency, ease in the provision of care, and represent a real solution to our rich country’s health system deficiencies.

Gordon has practiced family and preventive medicine in Pacific Beach and Ocean Beach since 1983. He completed a residency in family medicine at UCSD Medical Center and served eight years on the California Medical Board, which licenses and disciplines physicians and some allied health professionals.

http://www.signonsandiego.com/uniontrib/20080713/news_mz1e13gordon.html

Health care as a right is hard sell, except outside U.S.

By Wendi C. Thomas
Memphis Commercial Appeal
Sunday, July 13, 2008

What is it like to be sick outside of the United States?

Well, if you are among the 47 million uninsured or 25 million underinsured in America, health care in capitalist democracies such as Switzerland, Germany, Japan, Great Britain or Taiwan is decidedly better than the broken system we have here.

Switzerland requires all its citizens to have coverage.

In Germany, co-payments are only $15 every three months. In Japan, health insurance is private and patients can see a specialist whenever they like.

In Great Britain, doctors get bonuses for improving their patients’ health. Taiwan stores its citizens’ medical histories on electronic cards, which slashes administrative costs.

And in none of these countries do people go bankrupt because of unpaid medical bills.

How do I know this? Because I was at the state’s first house party for the Frontline documentary “Sick Around The World,” a screening organized by the Tennessee Health Care Campaign and the Tennessee Chapter of Physicians for a National Health Program. Retired doctor Art Sutherland is the president of the latter group, and Wednesday night he brought about 30 people into his East Memphis home.

These were people who, for the most part, have health insurance. For them, a lack of health care does not — at least not today — force them to choose between medicine or food.

But they realize that for too many Tennesseans, including the estimated 14 percent who are uninsured, the lack of health care is a matter of life and death.

There is no perfect system — not in any of the countries featured in the documentary, nor in any country in the world. In fact, the documentary made clear that most of the foreign systems don’t bring in enough money to cover the costs.

Unlike Michael Moore’s “Sicko,” this documentary isn’t a politically charged indictment against America as much as it is a call to glean universal health care lessons from our global neighbors.

After all, if Taiwan can insure all its citizens, why can’t we?

Why don’t we?

“It’s a really hard sell that health care is a right,” said Charlotte Borst, a Rhodes College history professor on sabbatical this year. “To me, that’s the biggest issue.”

Once we agree that health care is a right, everything else, Borst believes, is just a matter of figuring out the details of a universal health care system.

One of those who viewed the hourlong documentary was Sandy Arnold, a pediatrician at Le Bonheur Children’s Medical Center and formerly a doctor in Canada.

“It’s part of the Canadian national identity,” Arnold said, that health care for all is a right, and one of the values that distinguishes them from their neighbor to the south.

And therein lies America’s rub. We believe the government is responsible for providing every child an education, and everyone police protection, even that an ambulance should attend to your emergent medical needs.

But the right to health care? In America? It’s not yet part of our national identity.

Shifting that tide — and winning the inevitable fight with the health care and pharmaceutical industries — could take years.

But in the meantime, Sutherland and Emily Snyder, West Tennessee coordinator for the Tennessee Health Care Campaign, hope that voters educate themselves on Sens. John McCain’s and Barack Obama’s health care proposals before heading to the polls. (Get a side-by-side comparison of the presidential candidates’ ideas at health08.org.)

“The United States needs to use its American ingenuity and use the sense of fairness I think we still have to solve this,” Sutherland said.

To get involved

The local organizing group of the Tennessee Health Care Campaign meets next at 5 p.m. Tuesday at the Memphis Center for Independent Living, 1633 Madison. The group meets on the third Thursday of each month, same time and place.

For more information about the organization or hosting your own house party to screen “Sick Around The World,” contact Emily Snyder, the West Tennessee coordinator for the Tennessee Health Care Campaign (thcc2.org), at esnyder@thcc2.org or 590-4873.

Americans down on the U.S. health-care system

Dutch rate theirs most favorably of 10 industrialized nations

By Kristen Gerencher
MarketWatch
July 13, 2008

SAN FRANCISCO (MarketWatch) — International comparisons of health-care systems can be tricky to tease out, but the Dutch appear most satisfied with their system and Americans the least satisfied, according to a new survey of 10 industrialized countries.

The Dutch system was most popular with its citizens while adults in the U.S. were itching for national reform the most, according to Harris Interactive, which cited three separate data sets.

A third of Americans said they believe the U.S. system “has so much wrong with it that we need to completely rebuild it,” while only 9% in the Netherlands hold such a sentiment about their health-care system. Twelve percent of Spaniards favored a complete overhaul, compared with 15% in France, 17% in New Zealand, 18% in Australia and 20% in Italy.

People in the Netherlands also were most likely to say their health-care system works well and needs only minor changes, with 42% holding that view vs. 29% who said so in France. About a quarter of participants in Canada, New Zealand and Australia were fairly satisfied with their health care. The U.S. and Italy were least likely to want minimal changes, with only 12% and 11% supporting just minor tweaks, respectively.

Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University. Had the survey asked participants about their most recent hospital stay, for example, the U.S. likely would’ve scored higher, he said.

“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”
Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.

Americans’ feelings about the U.S. health-care system have remained stable over the last decade, with roughly twice as many saying they want a complete overhaul compared with other nations, said Karen Davis, president of the Commonwealth Fund, a private foundation in New York that has tracked the issue.

What’s more, Americans’ personal share of medical expenses is the highest in the industrialized world, Davis said. In 2007, 30% of Americans reported having out-of-pocket medical expenses of more than $1,000 in the last year compared with 19% of Australians, 12% of Canadians, 10% of Germans and New Zealanders, 5% of Dutch and 4% of Britons.

Accounting for success

The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.

Those polled as the change went into effect may have been reluctant to add any more reforms — even though the system functions pretty much the same way as before, he said.

“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”

Dutch health care also addresses patients’ need for medical attention during nonbusiness hours, Davis said. “The Netherlands has this amazing off-hours system of care so you can always get a nurse or doctor at night or in the evening.”

It’s not just Dutch patients who seem satisfied. In 2006, only 3% of physicians in the Netherlands said they thought their system needed a complete overhaul compared with 9% of U.K. doctors and 16% of doctors in the U.S, according to the Commonwealth Fund.

In some countries that have universal coverage, a sense of pride pervaded the participants’ answers, along with a smaller dose of concern about the systems’ sustainability. In Great Britain, nearly 70% agreed that the National Health Service must be maintained because it’s “crucial” to British society, according to the Harris Interactive survey. But 24% called it a “great enterprise” that probably can’t be maintained in its current form.

Contemplating trade-offs

Majorities in France (70%) and Britain (59%) said their health systems are the envy of the world. Still, nearly as many in France as in the U.S. said fundamental changes are needed to make the system work better. Half of American adults said so compared with 47% of French adults.

Victor Rodwin, professor of health policy and management at New York University’s Wagner School of Public Service, said the French and Danish have among the highest satisfaction rates in European polls of health-system perceptions.

“The French tend to defend their system because they look across the channel and see the British system of rationing and they say that’s not for them,” he said. “They look across the Atlantic and see the U.S. number of uninsured and high prices and say that’s not for them.”

At the same time, some French physicians complain that they’re underpaid and that the system is weighed down by wasteful spending and a lack of responsiveness to consumer preferences, Rodwin said.

In France, people automatically receive a standard, generous insurance benefit that includes prescription drug coverage, he said. They have no deductibles but small copayments. The system is financed largely through taxes.
“What makes France unique is there’s such good access not only to primary care, which you also get in Britain, but also to specialty care,” Rodwin said. “And there’s a high premium on patient choice.”

To be sure, France has one of the most expensive health-care systems in Europe, with expenditures totaling about 11% of its gross domestic product. The U.S. spends 16% of its GDP on health care. Cost containment has been an issue in France for the last 20 years, but unlike the U.S., lawmakers there aren’t talking about national health reform, Godwin said.

Still, cost concerns are growing, he said. “There is an increasing realization that this cannot last forever. There’s constantly new technology and pressure to cover all this and deliver it to the entire population.”

Harris Interactive tapped three sources for its findings. The data for France, Italy, Spain and Germany come from an FT/Harris Poll conducted in June 2008 for the Financial Times. The data for the U.S. and Great Britain come from a Harris Interactive survey conducted for the International Herald Tribune and France 24 in May 2008. The data for the Netherlands, Canada, New Zealand and Australia come from a Harris Interactive survey conducted for the Commonwealth Fund between March and May 2007.

Kristen Gerencher is a reporter for MarketWatch in San Francisco.

A system ‘in the process of collapse’

By Jeoffry B. Gordon
The San Diego Union-Tribune
July 13, 2008

As a family doctor who has practiced in San Diego for more than 25 years, my daily, intimate experience of providing medical care leads me to strongly dissent from Grace-Marie Turner’s views in “How good is our health care system?” (Opinion, June 30).

Daily I see patients without health insurance who have avoided care, omitted pharmaceuticals they could not afford, or had to use emergency rooms at times of true need and incurred extraordinarily huge charges. Every two or three months I see a patient literally at death’s door due to illness previously unexamined due to financial fears.

Turner does not discuss the fact that bills due to the costs of illnesses are the largest cause of personal bankruptcies in the United States. She omits any discussion of the 47 million uninsured citizens (5 million citizens and 2 million noncitizens in California) cast aside by our “good” health care system to fend as they may.

As a case in point, it is important to note that the American Cancer Society has devoted its annual campaign this year to promoting universal access to medical care. It has determined that being poor or uninsured markedly impairs outcomes of cancer patients, and that making improvements in organizing and financing medical services would save more lives than promoting any scientific or technical innovations in the practice of oncology.

Turner omits any reference to the fact that administrative overhead and profits consume between 20 and 30 percent of health care insurance premium dollars, diverting much of these resources from the provision of health services to enrollees. The total value of money not spent on health services by health insurance companies in the United States approaches $400 billion a year — an amount that approximates the total budget of the Pentagon in 2007 (omitting supplemental appropriations for the Iraq war).

Furthermore, in my own practice I must devote about 5 percent of my time and 25 per cent of my staff time to dealing with the extraordinary complexities of multiple insurance companies and their rules. These are additional resources diverted away from patient care.

Evidently, Turner advocates for a “free-market” approach to medical care. Turning the provision of medical care from a profession into a commercial business has also had a huge impact in distorting the system of health care resources.

There is a huge deficit in (less well paid) general internists, geriatricians and family doctors; there is a surplus of fancy (and expensive) MRIs and PET scanners, etc; public health and sanitation are underfunded (see the current epidemic of tomato-born diarrhea); all resources are scarce in rural areas, and so on. These considerations demonstrate economic as well as production inefficiencies that no “business” would or could tolerate except under cartel conditions when consumers are weak and extraordinary profits can be made.

Frankly, I think the private personal health insurance system is in the process of collapse. Limitations of benefits and cost-sharing (premiums, coinsurance and deductibles) to limit care and improve profit are becoming so onerous that both businesses and individual families are going without, and an extraordinary bureaucracy is smothering health care providers.

The universal tax-financed health insurances we have for people over 65 (Medicare) and veterans and military (Tricare) are both more economically efficient and user-and provider-friendly. In my opinion, a Medicare-for-All program or single-payer health system (such as envisioned in California Senate Bill 840) would provide a tremendous advance in economic efficiency, ease in the provision of care, and represent a real solution to our rich country’s health system deficiencies.

Gordon has practiced family and preventive medicine in Pacific Beach and Ocean Beach since 1983. He completed a residency in family medicine at UCSD Medical Center and served eight years on the California Medical Board, which licenses and disciplines physicians and some allied health professionals.

http://www.signonsandiego.com/uniontrib/20080713/news_mz1e13gordon.html

Text of Resolution adopted by the U.S. Conference of Mayors at its 76th Annual Meeting, June 23, 2008, in Miami, FL

Resolution in support of the United States National Health Insurance Act, H.R. 676

Submitted By:
The Honorable Lois J. Frankel, Mayor of West Palm Beach, Fla.
The Honorable Wayne J. Hall Sr., Mayor of Hempstead, N.Y.
The Honorable Carolyn K. Peterson, Mayor of Ithaca, N.Y.
The Honorable John E. Marks III, Mayor of Tallahassee, Fla.
The Honorable Sheila Dixon, Mayor of Baltimore, Md.
The Honorable Becky Tooley, Mayor of Coconut Creek, Fla.
The Honorable Ryan Coonerty, Mayor of Santa Cruz, Calif.

WHEREAS, every person deserves access to affordable quality health care; and

WHEREAS, the number of Americans without health insurance now exceeds 47 million; and

WHEREAS, millions with insurance have coverage so inadequate that a major illness would lead to financial ruin, and medical illness and bills contribute to one-half of all bankruptcies; and

WHEREAS, proposals for “consumer directed health care” such as Health Savings Accounts or Health Reimbursement Accounts (HRAs) would only worsen this situation by penalizing the sick, discouraging prevention and saddling many working families with huge medical bills; and

WHEREAS, managed care and other market-based reforms have failed to contain health care costs, which now threaten the international competitiveness of U.S. manufacturers; and

WHEREAS, administrative waste stemming from our reliance on private insurers consumes one-third of private health spending while the single payer Medicare system has administrative costs of less than 5 percent; and

WHEREAS, U.S. hospitals spend 24.3 percent of their budgets on billing and administration while hospitals under Canada’s single payer system spend only 12.9 percent; and

WHEREAS, Harvard researchers estimate that more than $300 billion could be recovered by replacing private insurance companies with a single public payer, enough to cover the uninsured and to improve coverage for all those who now have only partial coverage; and

WHEREAS, entrusting care to profit-oriented firms diverts billions of dollars to outrageous incomes for CEOs and threatens the quality of care; and

WHEREAS, The United States National Health Insurance Act (H.R. 676) would assure universal coverage of all medically necessary services, contain costs by slashing bureaucracy, protect the doctor patient relationship, assure patients a completely free choice of doctors, and allow physicians a free choice of practice settings; and

WHEREAS, most polls show that the majority of Americans support universal health care; and

WHEREAS, as of the date of this resolution, the majority of American physicians (59 percent) believe that Single Payer is the best method of securing universal health care; and

WHEREAS, The United States National Health Insurance Act (H.R. 676) will guarantee every mayor that all residents and employees of his/her city will be fully covered for health care and save millions of taxpayer dollars now spent on premiums to provide less than full health insurance coverage for government employees; and

NOW, THEREFORE,

BE IT RESOLVED, that the United States Conference of Mayors expresses its support for The United States National Health Insurance Act (H.R. 676), and calls upon federal legislators to work towards its immediate enactment and further urges the adoption of a process to insure that health care providers justify any increase in health care costs.

“Keeping the insurance you have” – Don’t believe it!

Statement of Common Purpose

Health Care for America Now!

“A choice of a private insurance plan, including keeping the insurance you have if you like it…”

http://healthcareforamericanow.org/site/content/about_us/

And…

Proposed GM/UAW VEBA: A House of Cards?

By Stephen Diamond
School of Law, Santa Clara University
October 2, 2007

This MOU (Memorandum of Understanding) makes clear that the entire VEBA (voluntary employees’ beneficiary association) structure fails to secure future health care obligations from the potential risk of GM (General Motors) bankruptcy. To put it succinctly, the VEBA structure can be said to balance like a house of cards completely subject to the ups and downs of GM’s financial future. If GM collapses into bankruptcy it is very likely that the VEBA will also collapse.

The basis of this conclusion is simple: according to the MOU GM retains unilateral power to make up to $7 billion of its potential contributions to the VEBA in cash over a twelve to twenty year period through annual payments. Since these payments are to be made in cash they depend entirely on the availability of that cash from GM. But if GM declares bankruptcy there is no means to guarantee now that the cash will be available or that GM will not use the bankruptcy process to shield itself from these future payment obligations. This compounds the problems associated with the Convertible Note whose value rises and falls with GM stock and whose annual interest payment and return of principal could be blocked in bankruptcy.

http://www.soldiersofsolidarity.com/files/relatednewsandreports07-2/GM-UAWVEBADealDescribedAsHouseofCards.html

Stephen F. Diamond, J.D., Ph.D., Associate Professor of Law:
http://www.scu.edu/law/faculty/profile/diamond-stephen.cfm

Comment:

By Don McCanne, MD

Pause for a minute. Think back to the insurance you had twenty years ago. Remember? Now… do you still have precisely that same coverage? Unless you are over 85 and have been in the traditional Medicare program for the past twenty years, it is highly likely that you do not.

Why not? After all, wasn’t the coverage then better and much less expensive than what you now have? Likely it provided you with a free choice of physicians and hospitals. It covered all reasonable health care services, maybe with small co-payments for routine services, and complete coverage for catastrophic expenses after a modest hospital deductible. Perhaps it was a non-profit Blue Cross or Blue Shield plan administered in the public interest, rather than today’s for-profit plans with a mission to maximize shareholder return by spending as little as possible on actual patient care. The fine print of the older insurance products designed to serve the patient was quite different from the fine print of today’s insurance products designed to compete in a profit-driven insurance market.

It is probable that your current coverage restricts you to a list of contracted physicians and hospitals, and assesses severe financial penalties if you obtain care outside of the plan. More plans today exclude from coverage some essential services such as obstetrical care and mental health services, and some even go so far as to exclude hospital coverage and specialist services. More of you are finding that the deductible and coinsurance in your plans are now large enough to cause financial hardship if you should develop significant health problems. Medical debt has become a major contributor to personal bankruptcy, and three-fourths of those with medical debt had health insurance when their problems started. All too commonly, health insurance now fails to perform its primary function: protecting us from financial hardship in the face of medical need.

So why do you no longer have the better coverage that you had twenty years ago? You may have changed jobs, likely more than once, and lost the coverage that your prior employer provided. Your employer may have changed plans because of ever-increasing insurance premiums. Frequently your insurer introduces plan innovations such as larger deductibles, a change from fixed-dollar copayments to higher coinsurance percentages, tiering of your cost sharing for services and products, reduction in the benefits covered, dollar caps on payouts, and other innovations all designed to keep premiums competitive in a market of rapidly rising health care costs. You may have lost coverage when your age disqualified you from participating in your parents’ plan. You may have found that health benefit programs have been declining as an incentive offered by new employers. Your children may have lost coverage under the Children’s Health Insurance Program when your income, though modest, disqualified your family from the program. Your union may not have been able to negotiate the continuation of the high-quality coverage that you previously held. Your employer may have reduced or eliminated the retirement coverage that you were promised but not guaranteed. Your employer may have filed for bankruptcy without setting aside the legacy costs of their pensions and retiree health benefit programs. You may have decided to start your own small business and found that you could not qualify for coverage because of your medical history, even if relatively benign, or maybe your small business margins are so narrow that you can’t afford the premiums. You may have been covered previously by a small business owner whose entire group plan was cancelled at renewal because one employee developed diabetes, or another became HIV infected. Your COBRA coverage may have lapsed and you found that the individual insurance market offered you no realistic options. You may have retired before Medicare eligibility, only to find that premiums were truly unaffordable or coverage was not even available because of preexisting medical problems.

Okay, so you say that your plan is an exception, and you want to keep it. You have or did have an employer that is so large and has such great resources that your plan will always be there, including throughout retirement. Well, let’s look at the largest and most successful private health program ever – that of General Motors. Twenty years ago, every General Motors employee knew that he or she had the best health plan available, and for life. Whoa. What was that about General Motors being saddled with legacy costs? This highly successful health program threatened to sink General Motors because of projected future commitments. They ducked that one by establishing a VEBA (voluntary employees’ beneficiary association) and dumped it on UAW (the auto workers union). UAW is now in a position of holding its breath, hoping that the VEBA does not collapse before we have adopted a national health program. Are you really sure that your secure lifetime coverage is stronger than that of General Motors? Don’t count on it.

The point is that hardly anyone under 85 has the same coverage that they had twenty years ago, and that has not been by choice. Factors over which you had very little or no control dictated that you could no longer keep the insurance you had. Today, the politicians promise you that you can keep the insurance you have, if that’s your choice, even though that has hardly ever been true in the past. Is there any reason to expect it to be true in the future?

The politicians propose token programs to control future health care cost increases, but none of these programs will have a significant impact. As long as we rely on a dysfunctional, fragmented system of public programs and private plans to finance health care, we will never control the true cost drivers that are making health care unaffordable for most of us. To keep insurance premiums affordable, the insurers will have no choice but to continue to introduce innovations in their products that will further diminish the capability of the plans to prevent financial hardship for those who need care. That means that you do not have the option of keeping the plan you have today, simply because the insurers will not be able to offer the same plan twenty years from now.

That applies to Medicare as well. It will not be the same in twenty years. But here there is hope. Medicare can be changed so that it works even better to allow us to have access to health care without the potential for financial ruin. If all of us were enrolled in a new and improved Medicare program, we would have the ability to address the true causes of escalating health care costs. We would dramatically reduce the profound administrative waste that is a direct result of trying to finance health care through a disconnected system of a multitude of private plans and public programs wherein none of the players has significant control over our global health care expenditures. A single Medicare-like program would be capable of realigning incentives to encourage the reinforcement of our primary care infrastructure in order to ensure that everyone has access to a system that provides higher quality care at a more reasonable cost. Incentives could also be altered to reduce ineffective and even detrimental high-tech excesses that drive up costs, while ensuring that beneficial high-tech services will always be there when we need them.

If we had a comprehensive, high quality, value-based Medicare system for everyone, then all of us would want to keep the system that we would have, not only for the next twenty years, but for the rest of our lives. In the meantime, don’t let the politicians tell you that you can keep the coverage you have. It likely won’t be there when you need it twenty years from now.

(This message will be posted on the PNHP Blog at https://www.pnhp.org/blog/ and your responses are invited.)

"Keeping the insurance you have" – Don't believe it!

Statement of Common Purpose

Health Care for America Now!

“A choice of a private insurance plan, including keeping the insurance you have if you like it…”

http://healthcareforamericanow.org/site/content/about_us/

And…

Proposed GM/UAW VEBA: A House of Cards?

By Stephen Diamond
School of Law, Santa Clara University
October 2, 2007

This MOU (Memorandum of Understanding) makes clear that the entire VEBA (voluntary employees’ beneficiary association) structure fails to secure future health care obligations from the potential risk of GM (General Motors) bankruptcy. To put it succinctly, the VEBA structure can be said to balance like a house of cards completely subject to the ups and downs of GM’s financial future. If GM collapses into bankruptcy it is very likely that the VEBA will also collapse.

The basis of this conclusion is simple: according to the MOU GM retains unilateral power to make up to $7 billion of its potential contributions to the VEBA in cash over a twelve to twenty year period through annual payments. Since these payments are to be made in cash they depend entirely on the availability of that cash from GM. But if GM declares bankruptcy there is no means to guarantee now that the cash will be available or that GM will not use the bankruptcy process to shield itself from these future payment obligations. This compounds the problems associated with the Convertible Note whose value rises and falls with GM stock and whose annual interest payment and return of principal could be blocked in bankruptcy.

http://www.soldiersofsolidarity.com/files/relatednewsandreports07-2/GM-UAWVEBADealDescribedAsHouseofCards.html

Stephen F. Diamond, J.D., Ph.D., Associate Professor of Law:
http://www.scu.edu/law/faculty/profile/diamond-stephen.cfm

Comment:

By Don McCanne, MD

Pause for a minute. Think back to the insurance you had twenty years ago. Remember? Now… do you still have precisely that same coverage? Unless you are over 85 and have been in the traditional Medicare program for the past twenty years, it is highly likely that you do not.

Why not? After all, wasn’t the coverage then better and much less expensive than what you now have? Likely it provided you with a free choice of physicians and hospitals. It covered all reasonable health care services, maybe with small co-payments for routine services, and complete coverage for catastrophic expenses after a modest hospital deductible. Perhaps it was a non-profit Blue Cross or Blue Shield plan administered in the public interest, rather than today’s for-profit plans with a mission to maximize shareholder return by spending as little as possible on actual patient care. The fine print of the older insurance products designed to serve the patient was quite different from the fine print of today’s insurance products designed to compete in a profit-driven insurance market.

It is probable that your current coverage restricts you to a list of contracted physicians and hospitals, and assesses severe financial penalties if you obtain care outside of the plan. More plans today exclude from coverage some essential services such as obstetrical care and mental health services, and some even go so far as to exclude hospital coverage and specialist services. More of you are finding that the deductible and coinsurance in your plans are now large enough to cause financial hardship if you should develop significant health problems. Medical debt has become a major contributor to personal bankruptcy, and three-fourths of those with medical debt had health insurance when their problems started. All too commonly, health insurance now fails to perform its primary function: protecting us from financial hardship in the face of medical need.

So why do you no longer have the better coverage that you had twenty years ago? You may have changed jobs, likely more than once, and lost the coverage that your prior employer provided. Your employer may have changed plans because of ever-increasing insurance premiums. Frequently your insurer introduces plan innovations such as larger deductibles, a change from fixed-dollar copayments to higher coinsurance percentages, tiering of your cost sharing for services and products, reduction in the benefits covered, dollar caps on payouts, and other innovations all designed to keep premiums competitive in a market of rapidly rising health care costs. You may have lost coverage when your age disqualified you from participating in your parents’ plan. You may have found that health benefit programs have been declining as an incentive offered by new employers. Your children may have lost coverage under the Children’s Health Insurance Program when your income, though modest, disqualified your family from the program. Your union may not have been able to negotiate the continuation of the high-quality coverage that you previously held. Your employer may have reduced or eliminated the retirement coverage that you were promised but not guaranteed. Your employer may have filed for bankruptcy without setting aside the legacy costs of their pensions and retiree health benefit programs. You may have decided to start your own small business and found that you could not qualify for coverage because of your medical history, even if relatively benign, or maybe your small business margins are so narrow that you can’t afford the premiums. You may have been covered previously by a small business owner whose entire group plan was cancelled at renewal because one employee developed diabetes, or another became HIV infected. Your COBRA coverage may have lapsed and you found that the individual insurance market offered you no realistic options. You may have retired before Medicare eligibility, only to find that premiums were truly unaffordable or coverage was not even available because of preexisting medical problems.

Okay, so you say that your plan is an exception, and you want to keep it. You have or did have an employer that is so large and has such great resources that your plan will always be there, including throughout retirement. Well, let’s look at the largest and most successful private health program ever – that of General Motors. Twenty years ago, every General Motors employee knew that he or she had the best health plan available, and for life. Whoa. What was that about General Motors being saddled with legacy costs? This highly successful health program threatened to sink General Motors because of projected future commitments. They ducked that one by establishing a VEBA (voluntary employees’ beneficiary association) and dumped it on UAW (the auto workers union). UAW is now in a position of holding its breath, hoping that the VEBA does not collapse before we have adopted a national health program. Are you really sure that your secure lifetime coverage is stronger than that of General Motors? Don’t count on it.

The point is that hardly anyone under 85 has the same coverage that they had twenty years ago, and that has not been by choice. Factors over which you had very little or no control dictated that you could no longer keep the insurance you had. Today, the politicians promise you that you can keep the insurance you have, if that’s your choice, even though that has hardly ever been true in the past. Is there any reason to expect it to be true in the future?

The politicians propose token programs to control future health care cost increases, but none of these programs will have a significant impact. As long as we rely on a dysfunctional, fragmented system of public programs and private plans to finance health care, we will never control the true cost drivers that are making health care unaffordable for most of us. To keep insurance premiums affordable, the insurers will have no choice but to continue to introduce innovations in their products that will further diminish the capability of the plans to prevent financial hardship for those who need care. That means that you do not have the option of keeping the plan you have today, simply because the insurers will not be able to offer the same plan twenty years from now.

That applies to Medicare as well. It will not be the same in twenty years. But here there is hope. Medicare can be changed so that it works even better to allow us to have access to health care without the potential for financial ruin. If all of us were enrolled in a new and improved Medicare program, we would have the ability to address the true causes of escalating health care costs. We would dramatically reduce the profound administrative waste that is a direct result of trying to finance health care through a disconnected system of a multitude of private plans and public programs wherein none of the players has significant control over our global health care expenditures. A single Medicare-like program would be capable of realigning incentives to encourage the reinforcement of our primary care infrastructure in order to ensure that everyone has access to a system that provides higher quality care at a more reasonable cost. Incentives could also be altered to reduce ineffective and even detrimental high-tech excesses that drive up costs, while ensuring that beneficial high-tech services will always be there when we need them.

If we had a comprehensive, high quality, value-based Medicare system for everyone, then all of us would want to keep the system that we would have, not only for the next twenty years, but for the rest of our lives. In the meantime, don’t let the politicians tell you that you can keep the coverage you have. It likely won’t be there when you need it twenty years from now.

(This message will be posted on the PNHP Blog at https://pnhp.org/blog/ and your responses are invited.)

China's failed experiment with the market

From A National, Centrally Planned Health System To A System Based On The Market: Lessons From China

By Jin Ma, Mingshan Lu and Hude Quan
Health Affairs
July/August 2008

No other country has undergone health care reforms as dramatic as China’s. Starting in 1978, China reformed its health system from a governmental, centrally planned, and universal system to a heavily market-based one. Now, three decades later, the Chinese government openly acknowledges that the reforms failed and seeks new directions. This paper adds to the literature by examining China’s health care from a system perspective, describing its health services delivery, access, outcomes, and population health in the post-reform era. It also identifies the main issues in the current system and highlights the key lessons learned from China’s reform process.

http://content.healthaffairs.org/cgi/content/abstract/27/4/937

When Incentives And Professionalism Collide

By William C. Hsiao

As Jin Ma and colleagues observe, an unfettered market approach in China has reduced access to care, increased patients’ financial burden, and reduced emphasis on prevention and may have caused declines in quality and outcomes. A major driving force was that perverse incentives altered physicians’ behavior toward self-interest at the expense of patients, even where professional ethics dictated otherwise. Other nations, including India, are grappling with the profit motive and its consequences. Chinese leaders are attempting to deal with these problems by expanding public investment and reducing perverse incentives. However, profit motives remain a powerful, potentially offsetting feature of a reformed system.

http://content.healthaffairs.org/cgi/content/abstract/27/4/949

Comment:

By Don McCanne, MD

Fundamental human ethics and mores are the same the world around.

There are those of us who believe that the people of the United States possess some sort of a superior intellect that allows us to use the sterile tools of market economics to provide a better life for all of us, at least for those of us who are willing to put in a greater effort, without any compromise whatsoever in our ethical and moral principles.

Some of the intellectuals in China had decided that using market dynamics was just the solution that they needed to help modernize the Chinese health care system. Sterile, amoral business decisions allow the leeway to bring out the best in us… and the worst. China got the best for a few, and the worst for the many.

Our health care system represents both the best and the worst, but now is so expensive that we have reached a point that we must realign incentives to promote the best for everyone, and discourage the worst that is draining our resources while benefiting primarily those who are capitalizing on the market.

China’s great experiment with free market health care demonstrates, once again, that mankind’s mores and ethics are best supported by social solidarity, rather than by the market, when establishing policies designed to benefit us all. It is a lesson that most other nations have learned, but one with which we are still struggling.

China’s failed experiment with the market

From A National, Centrally Planned Health System To A System Based On The Market: Lessons From China

By Jin Ma, Mingshan Lu and Hude Quan
Health Affairs
July/August 2008

No other country has undergone health care reforms as dramatic as China’s. Starting in 1978, China reformed its health system from a governmental, centrally planned, and universal system to a heavily market-based one. Now, three decades later, the Chinese government openly acknowledges that the reforms failed and seeks new directions. This paper adds to the literature by examining China’s health care from a system perspective, describing its health services delivery, access, outcomes, and population health in the post-reform era. It also identifies the main issues in the current system and highlights the key lessons learned from China’s reform process.

http://content.healthaffairs.org/cgi/content/abstract/27/4/937

When Incentives And Professionalism Collide

By William C. Hsiao

As Jin Ma and colleagues observe, an unfettered market approach in China has reduced access to care, increased patients’ financial burden, and reduced emphasis on prevention and may have caused declines in quality and outcomes. A major driving force was that perverse incentives altered physicians’ behavior toward self-interest at the expense of patients, even where professional ethics dictated otherwise. Other nations, including India, are grappling with the profit motive and its consequences. Chinese leaders are attempting to deal with these problems by expanding public investment and reducing perverse incentives. However, profit motives remain a powerful, potentially offsetting feature of a reformed system.

http://content.healthaffairs.org/cgi/content/abstract/27/4/949

Comment:

By Don McCanne, MD

Fundamental human ethics and mores are the same the world around.

There are those of us who believe that the people of the United States possess some sort of a superior intellect that allows us to use the sterile tools of market economics to provide a better life for all of us, at least for those of us who are willing to put in a greater effort, without any compromise whatsoever in our ethical and moral principles.

Some of the intellectuals in China had decided that using market dynamics was just the solution that they needed to help modernize the Chinese health care system. Sterile, amoral business decisions allow the leeway to bring out the best in us… and the worst. China got the best for a few, and the worst for the many.

Our health care system represents both the best and the worst, but now is so expensive that we have reached a point that we must realign incentives to promote the best for everyone, and discourage the worst that is draining our resources while benefiting primarily those who are capitalizing on the market.

China’s great experiment with free market health care demonstrates, once again, that mankind’s mores and ethics are best supported by social solidarity, rather than by the market, when establishing policies designed to benefit us all. It is a lesson that most other nations have learned, but one with which we are still struggling.