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Bush's privatization agenda for Medicare

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Bush's privatization agenda for Medicare

By LAURA S. BOYLAN
Sacramento Bee
Wednesday, February 13, 2008

The Bush administration is eating away at the heart of Medicare.

The first assault was the Medicare Modernization Act of 2003. And the second assault is the budget that President Bush just submitted to Congress.

Before looking at these two, we should recognize that Medicare is one of our nation’s most efficient, successful and popular public programs. Under this single-payer program for the elderly, people report less hassle, easier access, lower out-of-pocket expenses and more satisfaction than those with private insurance.

Let’s face it: Medicare is a public oasis in the private desert that is the health care marketplace in America. We spend more than twice as much on health care, on average, as other developed nations, all of which provide universal coverage through predominantly public financing. What’s more, their health outcomes are usually superior to ours.

Market-based health care is a minefield of “perverse incentives:” Procedures are rewarded over prevention and administrative costs are enormous. It is estimated that one-third to one-fifth of U.S. medical expense outlays don’t improve health.

As a doctor, I know that my time with patients is at the core of a humanistic practice of medicine. And it’s also the most cost-effective way to deliver primary care. It is, however, the least reimbursable of all medical events. Physicians are more likely to order questionable tests and specialty referrals when in a rush. It provides a sense of thoroughness, a hedge of bets and, frankly, a patient-pleasing way to close the visit when the lines are getting too long. But it adds immensely to the costs of health care.

The waste and inefficiency are, well, un-American.

In a triumph of ideology over fiscal sobriety, of special interests over public health, the Bush administration is trying to privatize Medicare rather than expand it.

The Medicare Modernization Act of 2003 offered prescription drug coverage, but exclusively through private companies. Bizarrely, it prohibited the government from negotiating price discounts from the drug companies. As a result, Medicare Part D drug prices are more than 80 percent higher than the prices negotiated by Medicaid and Veterans Affairs.

One important but obscure component of the Medicare Modernization Act will soon come to haunt us. And that is the creation of an arbitrary 45 percent general revenue cap, which, when reached, will trigger program cutbacks, higher premiums or further privatization. Medicare financing comes from various sources including general revenue, payroll taxes, trust fund interest, and beneficiary premiums. The cap has yet to kick in, but the drug company giveaway was funded mostly through general revenue, so it will come soon.

Then there’s the current Bush budget. It proposes reducing payments to doctors and hospitals while preserving subsidies to inefficient and sometimes corrupt private insurance middlemen, who offer plans through the Medicare Advantage program. These middlemen cost up to 19 percent more per beneficiary than traditional Medicare despite selective enrollment of the healthy.

Fiscal sobriety and public health demand that Medicare be kept affordable by getting rid of inefficient subsidies and giveaways to industry, which add cost but not value to health care.

Don’t let the Bush Administration fool you: We can afford Medicare. The $6 billion it would cut next year from public Medicare is less than the cost of two weeks of the war in Iraq.

Medicare is the proud kernel of a single-payer America, where health care is a right and not a commodity, and everyone has the same health care coverage as their president.

We can’t let the Bush administration continue to gouge it.

About the writer: Dr. Laura S. Boylan is an assistant professor of neurology at New York University and a board member of Physicians for a National Health Program (www.pnhp.org).

Bush’s privatization agenda for Medicare

By LAURA S. BOYLAN
Sacramento Bee
Wednesday, February 13, 2008

The Bush administration is eating away at the heart of Medicare.

The first assault was the Medicare Modernization Act of 2003. And the second assault is the budget that President Bush just submitted to Congress.

Before looking at these two, we should recognize that Medicare is one of our nation’s most efficient, successful and popular public programs. Under this single-payer program for the elderly, people report less hassle, easier access, lower out-of-pocket expenses and more satisfaction than those with private insurance.

Let’s face it: Medicare is a public oasis in the private desert that is the health care marketplace in America. We spend more than twice as much on health care, on average, as other developed nations, all of which provide universal coverage through predominantly public financing. What’s more, their health outcomes are usually superior to ours.

Market-based health care is a minefield of “perverse incentives:” Procedures are rewarded over prevention and administrative costs are enormous. It is estimated that one-third to one-fifth of U.S. medical expense outlays don’t improve health.

As a doctor, I know that my time with patients is at the core of a humanistic practice of medicine. And it’s also the most cost-effective way to deliver primary care. It is, however, the least reimbursable of all medical events. Physicians are more likely to order questionable tests and specialty referrals when in a rush. It provides a sense of thoroughness, a hedge of bets and, frankly, a patient-pleasing way to close the visit when the lines are getting too long. But it adds immensely to the costs of health care.

The waste and inefficiency are, well, un-American.

In a triumph of ideology over fiscal sobriety, of special interests over public health, the Bush administration is trying to privatize Medicare rather than expand it.

The Medicare Modernization Act of 2003 offered prescription drug coverage, but exclusively through private companies. Bizarrely, it prohibited the government from negotiating price discounts from the drug companies. As a result, Medicare Part D drug prices are more than 80 percent higher than the prices negotiated by Medicaid and Veterans Affairs.

One important but obscure component of the Medicare Modernization Act will soon come to haunt us. And that is the creation of an arbitrary 45 percent general revenue cap, which, when reached, will trigger program cutbacks, higher premiums or further privatization. Medicare financing comes from various sources including general revenue, payroll taxes, trust fund interest, and beneficiary premiums. The cap has yet to kick in, but the drug company giveaway was funded mostly through general revenue, so it will come soon.

Then there’s the current Bush budget. It proposes reducing payments to doctors and hospitals while preserving subsidies to inefficient and sometimes corrupt private insurance middlemen, who offer plans through the Medicare Advantage program. These middlemen cost up to 19 percent more per beneficiary than traditional Medicare despite selective enrollment of the healthy.

Fiscal sobriety and public health demand that Medicare be kept affordable by getting rid of inefficient subsidies and giveaways to industry, which add cost but not value to health care.

Don’t let the Bush Administration fool you: We can afford Medicare. The $6 billion it would cut next year from public Medicare is less than the cost of two weeks of the war in Iraq.

Medicare is the proud kernel of a single-payer America, where health care is a right and not a commodity, and everyone has the same health care coverage as their president.

We can’t let the Bush administration continue to gouge it.

About the writer: Dr. Laura S. Boylan is an assistant professor of neurology at New York University and a board member of Physicians for a National Health Program (www.pnhp.org).

Making Medicaid patients better shoppers

CMS Proposes New Rules for Redesigning Medicaid

States Have Greater Flexibility in Benefits, Cost Sharing

Centers for Medicare and Medicaid Services (CMS)
February 21, 2008

Two new proposed rules that would give states unprecedented flexibility in designing their own Medicaid programs, including adjusting their benefit package to more closely align with beneficiary needs and requiring increased cost sharing by enrollees, were announced today by the Centers for Medicare and Medicaid Services (CMS).

The proposed rules would implement provisions of the Deficit Reduction Act of 2005 and the Tax Relief and Health Care Act of 2006. The rules are the latest in a series of regulations to implement the Administration’s goals of aligning Medicaid more closely with private market insurance and giving states more control over their Medicaid benefits packages.

“These new rules recognize that states are in the best position to design plans that provide Medicaid beneficiaries better health care for the same or even lower cost,” Health and Human Services Secretary Mike Leavitt said. “The proposed rules will result in patients having more choices and greater control over their health care decisions.”

Individuals with family incomes between 100 and 150 percent of the FPL may see some cost sharing while monthly premiums can be charged to individuals with incomes above 150 percent of the FPL. As in SCHIP, all cost sharing must be limited to no more than five percent of the family’s income. The 2008 FPL for a family of four is $21,200.

“Until passage of the DRA, states had few options, other than through waivers, to update the health benefit packages offered through their Medicaid programs to meet the needs of the people they serve,” CMS Acting Administrator Kerry Weems said. “These proposed changes allow states to use modern methods of providing health insurance coverage and encourage families to participate in their own health care decisions.”

http://www.cms.hhs.gov/apps/media/press/release.asp
(Click release for February 21, 2008)

Comment:

By Don McCanne, MD

So under the new rules, a family of four living at the federal poverty level ($21,200) can be granted “greater control over their health care decisions” by being granted the opportunity to use $1060 of their own income in order to make them better health care shoppers.

These are families who are not facing foreclosure on their homes (since they could never qualify to purchase them in the first place). They are not facing repossession of their automobiles (since they have, at best, a clunker, or they use public transportation). They are not impacted by a mandate to buy insurance on their clunker (since they have no funds to purchase the required coverage anyway). These are families who will not have to face additional credit card debt (since any cards they have are already maxed out, and they cannot qualify for new cards). These are families who are able to regularly experience new living environments (each time they are evicted for failing to pay their past due rent). These are families who have become very adept at budgeting (since they must stretch their $407 per week to cover their rent, food, clothing, utilities, transportation, school supplies, etc., etc.).

Many studies have shown that cost sharing in health care literally can be a death sentence, especially for those living at or near the poverty level. Secretary Leavitt and Administrator Weems already know this.

What kind of nation have we become?

The Corrosion of Medicine

The Corrosion of Medicine

Can the Profession Reclaim its Moral Legacy?

By John Geyman, M.D.

Medicine can no longer deny the extent to which unbridled self-interest has eroded its professionalism. As documented in earlier chapters, these excesses are pervasive throughout the profession, for all to see, involving patient care, education and research as well as academic medical centers and many of the profession’s organizations. The extent of deprofessionalization makes clear that the cause extends well beyond a few “bad apples.” If medicine is to restore its professionalism, the profession must accept responsibility for letting down the public trust, recommit itself to service over self-interest, and build effective mechanisms of self-regulation which can gain the public’s confidence.

Whether medicine will give up its customary defensive mode and respond positively to its moral and professional challenges is an open question. Despite its long struggle to maintain its independence, the profession has lost much of its autonomy as it increasingly serves corporate interests. In a more proactive stance, medicine may recognize a larger role of government as a potential force to support the context within which it can restore its professionalism. Business as usual will not serve the profession or the public well. The profession now has a window of opportunity to expand its vision and lead toward better health care for all Americans. To do so, it must involve itself with rebuilding the capability of public health and with advocacy for real health care reform, which leads us to the last chapters.

http://www.commoncouragepress.com/index.cfm?action=book&bookid=384

Comment:

By Don McCanne, MD

This book was very difficult to read, not because of the complexity of the topic, but rather because of the anguish felt over what has happened to our profession.

Although physicians have been complicit in the processes leading to the corrosion of medicine, their blame lies not with an active role in commercializing health care, but rather with passive acceptance of their role in our current model of health care that is controlled by business and market interests.

When you ask a physician what his/her occupation is, he/she does not say that I am a businessperson in the health care industry. Almost without exception, the response is, “I’m a physician.” That has much greater meaning than merely being engaged in an occupation that takes care of sick people. It is difficult to put into words, but every health care professional knows what I mean.

Although it was painful to be reminded of the compromises being made on behalf of the business of medicine, there is also real hope in the message in this book. You realize that it doesn’t have to be this way. We do not have to passively accept the role of being workers in an industry controlled by market entrepreneurs.

We can become active advocates of reform that places our patients first. If we take health care financing out of the hands of the MBAs and place it under the control of our own universal public financing system, the patients and physicians will be able partner together in achieving the best health care possible within the confines of our finite resources.

Financing reform is only the first step, but it makes the other necessary reforms possible. Not only will we restore our pride in ourselves when we say, “I am a physician,” our patients will once again understand the special meaning of medicine as a profession rather than as a mere business.

Will targeted policies work for the uninsured?

The U.S. Economy And Changes In Health Insurance Coverage, 2000-2006

Americans continued to lose their health insurance even as the economy improved.

by John Holahan and Allison Cook
Health Affairs
February 20, 2008

The number of uninsured Americans increased by 3.4 million between 2004 and 2006, despite improving economic conditions. In the first four years of the decade, during a period of economic recession, the number increased by 6.0 million. The dominant factor in both periods was a decline in employer-sponsored insurance coverage. Although the recent decline was less than that experienced from 2000 to 2004, growth in public coverage was small, and the number of uninsured people increased by 1.0 million children and 2.4 million adults. Employer coverage declined most for self-employed or small-firm workers, in the South, and among noncitizens.

The decline was much greater in the first period, reflecting poor economic conditions. But the rate of employer coverage continued to decline even when the economy improved.

For children, the decline in employer coverage was offset by large growth in Medicaid and SCHIP in the first four years of the decade. As states experienced deteriorating fiscal conditions, they adopted policies that restricted growth in these programs. As a result, the number of uninsured children increased by 1.0 million between 2004 and 2006, after having fallen by 400,000 between 2000 and 2004.

Between 2004 and 2006, employer coverage fell by 6.2 percent for those below 200 percent of the poverty level and by 0.6 percent for those at or above 400 percent of poverty. Thus, the data show that employer coverage is clearly declining at all income levels, but primarily among those with the lowest incomes.

The decline in employer coverage can be traced to greater increases in health insurance premiums than in wages. As health insurance becomes more and more expensive, it adds more to the cost of a worker’s total compensation package. To the extent that firms cannot shift this back to workers in the form of lower wages, they become less likely to offer coverage.

It is striking that the rate of employer coverage declined and the number of uninsured people increased even after the U.S economy rebounded from the recent recession. This erosion will likely continue, particularly for low-income workers, because the basic factors underlying it seem unlikely to change.

http://content.healthaffairs.org/cgi/content/full/hlthaff.27.2.w135/DC1

Comment:

By Don McCanne, MD

The fact that the number of uninsured continues to increase is certainly not news. But there are a couple of points in this article that should alarm us.

A rebounding economy was unable to stop the decline in coverage. In spite of favorable economic trends, employers found their health benefit programs to be less affordable, and more dropped their employees from coverage. Clearly we will not be able to rely on improvements in the economy alone to expand coverage to more individuals.

This report demonstrates that the decline in coverage is impacting all sectors of our society, though some more than others. This indicates that targeted programs cannot eliminate the problem since some sectors inevitably will be left out. Also alarming is the fact that incremental reforms more narrowly targeting selected populations is not working either.

As an example, the greatest “success” in recent years has been insuring more children through the SCHIP and Medicaid programs. Yet the gain of 400,000 insured children during 2000-2004 was more than offset by a loss of 1.0 million during 2004-2006 (years of economic recovery). That certainly cannot be classified as a health policy success, yet that is the best we can show for all of our incremental efforts.

When you look at the leading comprehensive proposals, policies are included to target the more vulnerable populations. Yet they are very weak on policies that will help the largest vulnerable group of all: middle-income individuals and families.

Relying on improvements in the economy for most of us, with safety-net welfare programs for the poor, will never get us to a program that guarantees reasonably comprehensive care for all of us. It will require the adoption of a health care financing system that automatically includes all of us, for our entire lives.

A Single-Payer Health System

The New York Times
Letter to the Editor
February 16, 2008

To the Editor:

Re “Growing Pains of Universal Coverage” (editorial, Feb. 9):

Employer-provided health insurance is seen as necessary in contributing to a state plan, but over the long term it creates more problems than it solves.

Almost everything else a state does to ensure that its citizens have insurance tends to undermine the need for, and the willingness of, employers to continue bearing the burden of providing it.

And by adding 20 percent or more in overhead in the form of marketing, processing enrollments and collecting premiums, private insurance makes costs even more unaffordable.

Both kinds of insurance must be seen for what they are: the Trojan horses of the American health care nonsystem. To be sustainable over the long term, a plan requires structural change in how health care is financed and delivered, and states simply don’t have the power to do this.

Nothing less than a single-payer public system administered nationally will do so.

John Steen
Meadville, Pa.
The writer is the former president of the American Health Planning Association.

Myths and Memes About Single-Payer Health Iinsurance in the United States: A Rebutal to Conservative Claims

By John P. Geyman
International Journal of Health Services
Vol. 35, Num. 1, Pages 63-90, 2005

Recent years have seen the rapid growth of private think tanks within the neoconservative movement that conduct “policy research” biased to their own agenda. This article provides an evidence-based rebuttal to a 2002 report by one such think tank, the Dallas-based National Center for Policy Analysis (NCPA), which was intended to discredit 20 alleged myths about single-payer national health insurance as a policy option for the United States. Eleven “myths” are rebutted under eight categories: access, cost containment, quality, efficiency, single-payer as solution, control of drug prices, ability to compete abroad (the “business case”), and public support for a single-payer system. Six memes (self-replicating ideas that are promulgated without regard to their merits) are identified in the NCPA report. Myths and memes should have no place in the national debate now underway over the future of a failing health care system, and need to be recognized as such and countered by experience and unbiased evidence.

Click here to download the entire article.

Lewin Group analysis of "Health Care for America"

Cost Impact Analysis for the "Health Care for America" Proposal

Prepared for The Economic Policy Institute
The Lewin Group (an Ingenix company)
February 15, 2008

Executive Summary

Under the Health Care for America Proposal, employers would be required to provide coverage or pay a payroll tax to have their workers covered under a newly created national health insurance pool called Health Care for America (HCA). Modeled on Medicare, Health Care for America would offer a single Medicare-like fee-for-service option (public HCA plan) and a selection of Health Maintenance Organizations (HMOs) or other private managed care plans (private HCA plans). People who do not have employer-sponsored insurance (ESI) would be covered under HCA, including those now covered under Medicaid and the State’s Children’s Health Insurance Program (SCHIP). The Proposal would provide subsidies for worker HCA premiums for those living below 300 percent of the Federal Poverty Level (FPL), and premium subsidies for non-workers enrolled in HCA who are living below 400 percent of the FPL.

We estimate that there were about 47.8 million uninsured people in the country in 2007. The Health Care for America (HCA) Proposal would reduce the number of uninsured by 46.5 million people (i.e., 97.3 percent of the uninsured), leaving only about 1.3 million people uninsured. Coverage under the proposal would be as follows:

* We estimate that 122.2 million people would be covered under ESI, compared with 157.0 million people under current law;

* About 128.6 million people would be covered through the newly created HCA pool; and

* Enrollment in Medicare and the TRICARE program (i.e., military retirees and dependents) would remain the same as under current law.

The Health Care for America Proposal would cover 46.5 million uninsured people without increasing national spending for health care, largely through lower provider reimbursement, administrative simplification and other features of the proposal. The spending effects of the Proposal include:

* Spending for health care services and prescription drugs nationally would increase by $53.2 billion in 2007 as the uninsured become covered;

* Administrative simplification would reduce administrative costs by about $25.4 billion in 2007;

* There would be additional savings of $27.9 billion due to changes in provider payments, requiring people to have and use a medical home, and government negotiation of prescription drug prices for people covered through HCA.

Federal government health spending would increase under the Health Care for America Proposal by $49.3 billion, after accounting for all offsets. Total program spending under HCA would be $417.7 billion in 2007 including benefits and administration. These costs would be offset by the following:

* Employer payroll taxes for firms that do not provide coverage ($106.8 billion);

* Premiums for individuals covered through HCA ($80.3 billion);

* Federal and state government savings to Medicaid and SCHIP that would be transferred to HCA ($160.1 billion); and

* Other savings and new federal revenues under the Proposal ($21.2 billion).

We estimate that state and local governments would save $21.2 billion as a result of savings to programs that traditionally serve the uninsured (i.e., safety net programs). There would be no immediate net savings to Medicaid and SCHIP for states because they are required to pay the amount saved to HCA to help fund the program (i.e., maintenance of effort for Medicaid SCHIP only). Over time, however, savings achieved by HCA would be shared with the states.

Overall we estimate that private employers spent about $442.7 billion on health care for workers and retirees in 2007 (excludes employee contribution). Under the Health Care for America Proposal, private employer health spending would decrease by $10 billion, reflecting that many firms will find it less costly to discontinue their health plans and pay a six percent payroll tax to enroll their workers in HCA. Changes in private employer spending include:

* Private employers who currently offer coverage would save $65.6 billion by discontinuing their insurance and enroll their workers in HCA by paying the tax;

* Private employers that currently do not offer coverage would spend $55.6 billion more due to the requirement that they either provide coverage or enroll their workers in HCA by paying the payroll tax;

* On average, firms that currently offer coverage would save $809 per worker and those that do not currently offer coverage would spend $1,568 more per worker.

The Health Care for America Proposal requires that individuals obtain coverage and automatically enrolls people who do not have insurance into the public HCA plan. It also provides subsidies to help low-income people pay premiums. Overall, families would save $23.3 billion primarily from lower out-of-pocket payments. However, other financing mechanisms that would be needed to fully fund the proposal (i.e., $49.3 billion) would reduce these savings to families.

The Health Care for America Proposal would control the growth in health spending as enrollment increases, by restricting provider payment increases, negotiating deeper drug discounts, and simplified administration. Thus, national health spending under the HCA Proposal will be lower than under current law. We estimate that under these cost controls, total national health spending over the 2008 through 2017 period would be about $1.04 trillion less than under current law over that same period.

http://www.sharedprosperity.org/hcfa/lewin.pdf

Health Care for America:
http://www.sharedprosperity.org/bp180.html

Comment:

By Don McCanne, MD

Why is this important? The “Health Care for America” proposal of Jacob Hacker provides the general basis for the health care reform proposals of the leading Democratic candidates.

Since this report was just released I have not had time to do an analysis of it. But I did take a quick look to see what it said about one of our most important concerns. How would the proposal make reasonably comprehensive health insurance affordable for average income families?

Regarding benefits covered: “Covered services under Health Care for America would include the services under the current Medicare program as well as comprehensive mental health, maternal and child health services and comprehensive prescription drug coverage, subject to a formulary.” So the benefits are better than Medicare.

What about family costs? The monthly HCA premium for a two-parent family at 400 percent of the federal poverty level ($84,800 for a family of four) would be $670 ($8040 for the year). A 6 percent payroll tax (nominally paid by the employer, but as a reduction in the employee’s income) paid into the HCA pool would be $5088. The maximum out-of-pocket spending ($500 deductible and 20 percent coinsurance) would be $5000.

If the family used no medical care, they would be responsible, directly and indirectly, for $13,128 just for their share of the coverage. That’s 14.6 percent of their income. If they also had $5000 in out-of-pocket spending, that would total $18,128 or 20.2 percent of their income. (The percentages would be worse if I hadn’t calculated the total income as $84,800 plus the $5088 payroll tax.)

Many policy experts consider 15 to 20 percent of income for health care to constitute a financial hardship. A single payer national health program could do better than that.

CORRECTION for the Quote of the Day, February 15, 2008, “Lewin Group Analysis of ‘Health Care for America'”

As I mentioned in my last comment, I had not done an analysis of the full Lewin Group report but had taken only a quick look to pull out some of the numbers to see whether insurance under the proposal would be affordable.

In the calculation I added to the 6 percent payroll tax a premium of $670 per month (for a two-parent family at 400 percent of the federal poverty level). That was incorrect since that is the premium that non-workers would pay. The correct premium for a worker whose employer is paying the payroll tax would be $200 for a two-parent family at 300 percent of the federal poverty level. Obviously my quick look was too quick.

The calculations are revised for a two-parent family at 300 percent of the federal poverty level or $63,600 (the income level at which the premium is fully phased in). A family that used no medical care would be directly responsible for the $2400 premium plus indirectly responsible for $3816 in payroll taxes, or a total of $6216. That is 9.2 percent of their total income of $67,416 ($63,600 plus the employer payment of $3816 on the employee’s behalf). If they also had out-of-pocket expenses of $4770 (capped at 7.5 percent of $63,600 in direct income) that would be 16.3 percent of their total income of $67,416.

For non-workers, premiums are fully phased in at 400 percent of the federal poverty level or $84,800. For a two-parent family the annual premium would be $8040 or 9.5 percent of their income. If they too had out-of-pocket expenses of $5000 (plan cap on cost sharing) that would total 15.4 percent of their income.

When the average premium for employer-sponsored coverage is already over $12,000 per year, these family payments of $6216 and $8040 seem low. In fact, for an individual, the report states, “We estimate average enrollee costs in Health Care for America would be about $3250 compared to $4230 under a private insurance product in 2007.”

Does that seem reasonable? They state, “Health Care for America premiums would be lower than comparable private insurance due to lower provider payment rates, administrative costs and low-income subsidies.” The low-income subsidies do not apply to the two examples above, both middle-income families. Although they do discuss administrative savings in the report, it is likely that the amount is much smaller than they suggest because they fail to recover much of the waste inherent in a multi-payer system. And the lower provider payment rates? I’ll let you think about that one.

I do wish to express my profound apologies for having used incorrect numbers in my last message. It is important that we make every effort to maintain full credibility in our dialogue. But even the corrected numbers still pose significant problems.

It reminds me of the mathematician, the accountant and the economist who were each asked to solve the problem of two plus two. The mathematician said four, the accountant said four, plus or minus ten percent, and the economist asked, “What do you want it to be?”

Rather than crafting health care financing based on individual plans, whether public or private, it would be far more efficient and equitable to totally separate health care financing from the delivery of health care services. Establish a single, universal risk pool, funded equitably through the tax system, and then use that common pool to fund health care.

Then we would no longer have to tell the economists that we want a plan that provides comprehensive benefits, but it has to have a premium that’s affordable. That may be what we want the plan to be, but we can’t ignore the simple math behind the program.

Finally, I wish to express my profound admiration and respect for the individuals supporting the “Health Care for America” proposal. They share precisely the same goal as ours – comprehensive, high-quality, affordable health care for everyone. With the most noble of intentions, they have crafted a proposal that they believe meets the test of political feasibility while accepting what they would hope to be only temporary, modest compromises on the path to reform.

Our only substantial difference is that we believe that we should not begin from a position of compromise. The private insurance industry has to go.

The real Irony of the Health Care Mandate Arguments

by DrSteveB
DailyKos
Thu Feb 14, 2008 at 08:19:11 PM PST

The real irony of the Obama vs. Hillary (and Krugman and Baker & Hacker et al) argument over individual mandates for purchasing health insurance, is even more fundamental then they are both right and they are both wrong.

The argument against individual mandates is both political and practical. They can’t really be enforced, and they are political poison.

The joke, the irony, is that individual mandates have been promoted, in part — by the oh so moderate and well minded people on our side who should know better — exactly because they thought this approach was more policically practical then Single Payer (which they actually do know is the only plan that actually, you know, works)!

The lesson of 1993-1994, already learned by some of us, is that no matter what is proposed, it will be attacked by the Health Insurance industry, Pharma, the Right.

It does not matter what compromies you make ahead of time.

It will be attacked afterwards, regardless.

If it can provide affordable and universal coverage and access to care — which at the very least requires accepting all applicants (guaranteed issue) and moderating the variation in premiums by more effectively pooling risk (larger universal insurance pools and community rating) AND somehow controlling costs including excess profit and overhead (15-18% for the privates, 4% for Medicare) it will be attacked. If it reduces Health Insurance and Pharma corporate profits and control it will be attacked.

And, as Newt Gingrich and Bill Kristol famously pointed out back in 1993-94, if it looks like it might result in a success, it has to be attacked.

So yes… as analyzed by Clinton’s advisor and respected MIT health economics Jonathan Gruber and also by our friends at the Urban Institute (and endlessly reiterated by Krugman)… in principle

absent a single payer system, it is not possible to achieve universal coverage without an individual mandate. The evidence is strong that voluntary measures alone would leave large numbers of people uninsured. Voluntary measures would tend to enroll disproportionate numbers of individuals with higher cost health problems, creating high premiums and instability in the insurance pools in which they are enrolled, unless further significant government subsidization is provided. The government would also have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage.

Me… I reject the false premise.

In fact, plans depending on forced purchase of private insurance via individual mandates don’t really work either. As Don McCanne, PNHP’s Senior Health Policy Fellow, pointed out:

It is important to understand Professor Gruber’s framing and modeling since he is an advisor for various reform efforts such as those in Massachusetts and California, and he is also providing support for the proposals of leading Democratic candidates for president.

Although this paper presents modeling of “the impact of alternative interventions to increase insurance coverage,” he begins with assumptions that significantly limit the variety of options studied.
He limits his options based on “two political constraints.”

“First, it is difficult to envision a solution to the problem of the uninsured which does not involve in some way the private insurance industry… The health insurance industry in the United States has revenues of over $500 billion per year, making it a very concentrated interest that would have to be defeated to move to nationally provided health insurance.”

“The second constraint is the fiscal situation of the U.S.
government. Except for a brief window at the end of the 20th century, the U.S. government budget has been in significant deficit for thirty years, and this deficit shows no sign of abating… Given these pressures, major new expenditures to cover the uninsured are likely to engender a major political battle.”

Before he has even begun his analysis, he eliminates a single payer national health program because we must involve the private insurance industry, in spite of his acknowledgment of the high administrative costs.

Also, his modeling does not look at the impact on our total health care costs, but rather he models the impact on taxpayer costs. In so doing, he has placed a very high priority on keeping the costs of the expansions of health care coverage out of our government budgets, demonstrating that the biggest “bang for the buck” is attained by those alternatives that result in the lowest taxpayer cost per each additional individual obtaining coverage, ignoring the fact that the difference must be paid by individuals and/or employers.

He discusses two “modest reforms”: public insurance expansion, and non-group tax credits, which are quite inadequate compared to the need.

Then, for “more fundamental reform,” he states that issues to be addressed include pooling, affordability, and mandates. He considers three options, “given the constraint that private insurance provision must be a centerpiece of any reform plan.”

His first option is to ensure universal access of individuals to an affordable insurance product. He describes state-specific pools that are community rated with guaranteed issue. Voluntary participation would be encouraged by sliding scale subsidies based on income. By his modeling, this would cover about one-half of the uninsured, at a high taxpayer cost of $4500 per individual (Obama plan – per Krugman).

His second option is to add an individual mandate to this universal access approach. He makes the assumption, without supporting evidence (theorizing that strong penalties would be effective), that “95% of those who would not voluntarily choose to insure are forced to insure through the mandate.” By his modeling, this would cover about 97% of the uninsured at a lower taxpayer cost of $2732 per newly insured (Clinton plan – per Krugman).

His third option is to remove the tax subsidy (regressive) for employer-sponsored insurance and use those funds for the pools in the individual mandate approach. The tax subsidy is so great ($200 billion) that this would result in a negative cost per dollar of insurance provided (individual mandate cost of $120 billion). But once again, this is a reduction in government spending (a government subsidy not granted) with a redistributive shift between employers and individuals of varying incomes.

Professor Gruber concludes, “To fundamentally control health care costs we need to actually be willing to deny care that does little for health – but which consumers now want. This would be accomplished either through government technology policy, medical standards, or global provider budgets… The fundamental insight of this round of reform is therefore to not hold the attainable goal (universal coverage) hostage to the (currently) unattainable goal, fundamental health care cost control.”

But isn’t that the problem? Health care costs are now so high that private insurers can no longer provide us with reasonably comprehensive plans at premiums that are affordable for middle-income individuals.

His first option of pooling (community rating and guaranteed issue) cannot make the plans affordable. His second option of an individual mandate can’t work simply because the plans are not affordable, especially when he has made keeping government budgets in check a major priority. His third option corrects a tax policy injustice, but, in itself, is hardly a reason to perpetuate the inefficiencies and injustices of the private health plans.

Jonathan Gruber and Paul Krugman deserve their reputations as being amongst the most respected economists in the nation. But their fixation on individual mandates provides about the same level of insight as to what we need in the way of health financing reform as does the insight provided by the proctologist who tries to tell us our general state of health from his perspective.

But as we have seen with the relative political success of Obama’s (gentle compared to what the Repugs will bring) critique, individual mandates are neither implementable and enforceable in the real world, nor somehow an a priori compromise that is politically viable.

An Overview Introduction to What We Mean By Single Payer:

Single-payer national health insurance is a system in which a single public or quasi-public agency organizes health financing, but delivery of care remains largely private.

Currently, the U.S. health care system is outrageously expensive, yet inadequate. Despite spending more than twice as much as the rest of the industrialized nations ($7,129 per capita), the United States performs poorly in comparison on major health indicators such as life expectancy, infant mortality and immunization rates. Moreover, the other advanced nations provide comprehensive coverage to their entire populations, while the U.S. leaves 46 million completely uninsured and millions more inadequately covered.

The reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers. Private insurers necessarily waste health dollars on things that have nothing to do with care: overhead, underwriting, billing, sales and marketing departments as well as huge profits and exorbitant executive pay. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy. Combined, this needless administration consumes one-third (31 percent) of Americans’ health dollars.

Single-payer financing is the only way to recapture this wasted money. The potential savings on paperwork, more than $350 billion per year, are enough to provide comprehensive coverage to everyone without paying any more than we already do.

Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, long-term care, mental health, dental vision, prescription drug and medical supply costs. Patients would regain free choice of doctor and hospital, and doctors would regain autonomy over patient care.

Physicians would be paid fee-for-service according to a negotiated formulary or receive salary from a hospital or nonprofit HMO or other group practice. Hospitals would receive a global budget for operating expenses. Health facilities and expensive equipment purchases would be managed by regional health planning boards.

A single-payer system would be financed by eliminating private insurers and recapturing their administrative waste. Modest new taxes would replace premiums and out-of-pocket payments currently paid by individuals and business. Costs would be controlled though negotiated fees, global budgeting and bulk purchasing.

Key Features of “Pure” Single-Payer:

· Universal, Comprehensive Coverage:
Only this ensures access, avoids a 2-class system & minimizes expense

· No out-of-pocket payments:
Co-payments and deductibles are barriers to access, administratively unwieldy, and unnecessary for cost containment

· A single insurance plan, administered by a public or quasi-public agency:
A fragmentary payment system that entrusts private firms with administration ensures the waste of billions of dollars on useless paper pushing and profits. Private insurance duplicating public coverage fosters two-class care and drives up costs; such duplication should be prohibited

· Global operating budgets for hospitals, nursing homes, HMOs and other providers with separate allocation of capital funds:
Billing on a per-patient basis creates unnecessary administrative complexity and expense. Allowing diversion of operating funds for capital investments or profits undermines health planning and intensifies incentives for unnecessary care (under fee for service) or understatement (in HMOs)

· Free Choice of Providers:
Patients should be free to seek care from any licensed health care provider, without financial incentives or penalties

· Public Accountability, Not Corporate Dictates:
The public has an absolute right to democratically set overall health policies and priorities, but medical decisions must be made by patients and providers rather than dictated from afar. Market mechanisms principally empower employers and insurance bureaucrats pursuing narrow financial interests

· Ban on For-Profit Health Care Providers:
Profit seeking inevitably distorts care and diverts resources from patients to investors

· Protection of the rights of health care and insurance workers:
A single-payer national health program would eliminate the jobs of hundreds of thousands of people who currently perform billing, advertising, eligibility determination, and other superfluous tasks. These workers must be guaranteed retraining and placement in meaningful jobs.

Lewin Group analysis of “Health Care for America”

Cost Impact Analysis for the “Health Care for America” Proposal

Prepared for The Economic Policy Institute
The Lewin Group (an Ingenix company)
February 15, 2008

Executive Summary

Under the Health Care for America Proposal, employers would be required to provide coverage or pay a payroll tax to have their workers covered under a newly created national health insurance pool called Health Care for America (HCA). Modeled on Medicare, Health Care for America would offer a single Medicare-like fee-for-service option (public HCA plan) and a selection of Health Maintenance Organizations (HMOs) or other private managed care plans (private HCA plans). People who do not have employer-sponsored insurance (ESI) would be covered under HCA, including those now covered under Medicaid and the State’s Children’s Health Insurance Program (SCHIP). The Proposal would provide subsidies for worker HCA premiums for those living below 300 percent of the Federal Poverty Level (FPL), and premium subsidies for non-workers enrolled in HCA who are living below 400 percent of the FPL.

We estimate that there were about 47.8 million uninsured people in the country in 2007. The Health Care for America (HCA) Proposal would reduce the number of uninsured by 46.5 million people (i.e., 97.3 percent of the uninsured), leaving only about 1.3 million people uninsured. Coverage under the proposal would be as follows:

* We estimate that 122.2 million people would be covered under ESI, compared with 157.0 million people under current law;

* About 128.6 million people would be covered through the newly created HCA pool; and

* Enrollment in Medicare and the TRICARE program (i.e., military retirees and dependents) would remain the same as under current law.

The Health Care for America Proposal would cover 46.5 million uninsured people without increasing national spending for health care, largely through lower provider reimbursement, administrative simplification and other features of the proposal. The spending effects of the Proposal include:

* Spending for health care services and prescription drugs nationally would increase by $53.2 billion in 2007 as the uninsured become covered;

* Administrative simplification would reduce administrative costs by about $25.4 billion in 2007;

* There would be additional savings of $27.9 billion due to changes in provider payments, requiring people to have and use a medical home, and government negotiation of prescription drug prices for people covered through HCA.

Federal government health spending would increase under the Health Care for America Proposal by $49.3 billion, after accounting for all offsets. Total program spending under HCA would be $417.7 billion in 2007 including benefits and administration. These costs would be offset by the following:

* Employer payroll taxes for firms that do not provide coverage ($106.8 billion);

* Premiums for individuals covered through HCA ($80.3 billion);

* Federal and state government savings to Medicaid and SCHIP that would be transferred to HCA ($160.1 billion); and

* Other savings and new federal revenues under the Proposal ($21.2 billion).

We estimate that state and local governments would save $21.2 billion as a result of savings to programs that traditionally serve the uninsured (i.e., safety net programs). There would be no immediate net savings to Medicaid and SCHIP for states because they are required to pay the amount saved to HCA to help fund the program (i.e., maintenance of effort for Medicaid SCHIP only). Over time, however, savings achieved by HCA would be shared with the states.

Overall we estimate that private employers spent about $442.7 billion on health care for workers and retirees in 2007 (excludes employee contribution). Under the Health Care for America Proposal, private employer health spending would decrease by $10 billion, reflecting that many firms will find it less costly to discontinue their health plans and pay a six percent payroll tax to enroll their workers in HCA. Changes in private employer spending include:

* Private employers who currently offer coverage would save $65.6 billion by discontinuing their insurance and enroll their workers in HCA by paying the tax;

* Private employers that currently do not offer coverage would spend $55.6 billion more due to the requirement that they either provide coverage or enroll their workers in HCA by paying the payroll tax;

* On average, firms that currently offer coverage would save $809 per worker and those that do not currently offer coverage would spend $1,568 more per worker.

The Health Care for America Proposal requires that individuals obtain coverage and automatically enrolls people who do not have insurance into the public HCA plan. It also provides subsidies to help low-income people pay premiums. Overall, families would save $23.3 billion primarily from lower out-of-pocket payments. However, other financing mechanisms that would be needed to fully fund the proposal (i.e., $49.3 billion) would reduce these savings to families.

The Health Care for America Proposal would control the growth in health spending as enrollment increases, by restricting provider payment increases, negotiating deeper drug discounts, and simplified administration. Thus, national health spending under the HCA Proposal will be lower than under current law. We estimate that under these cost controls, total national health spending over the 2008 through 2017 period would be about $1.04 trillion less than under current law over that same period.

http://www.sharedprosperity.org/hcfa/lewin.pdf

Health Care for America:
http://www.sharedprosperity.org/bp180.html

Comment:

By Don McCanne, MD

Why is this important? The “Health Care for America” proposal of Jacob Hacker provides the general basis for the health care reform proposals of the leading Democratic candidates.

Since this report was just released I have not had time to do an analysis of it. But I did take a quick look to see what it said about one of our most important concerns. How would the proposal make reasonably comprehensive health insurance affordable for average income families?

Regarding benefits covered: “Covered services under Health Care for America would include the services under the current Medicare program as well as comprehensive mental health, maternal and child health services and comprehensive prescription drug coverage, subject to a formulary.” So the benefits are better than Medicare.

What about family costs? The monthly HCA premium for a two-parent family at 400 percent of the federal poverty level ($84,800 for a family of four) would be $670 ($8040 for the year). A 6 percent payroll tax (nominally paid by the employer, but as a reduction in the employee’s income) paid into the HCA pool would be $5088. The maximum out-of-pocket spending ($500 deductible and 20 percent coinsurance) would be $5000.

If the family used no medical care, they would be responsible, directly and indirectly, for $13,128 just for their share of the coverage. That’s 14.6 percent of their income. If they also had $5000 in out-of-pocket spending, that would total $18,128 or 20.2 percent of their income. (The percentages would be worse if I hadn’t calculated the total income as $84,800 plus the $5088 payroll tax.)

Many policy experts consider 15 to 20 percent of income for health care to constitute a financial hardship. A single payer national health program could do better than that.

CORRECTION for the Quote of the Day, February 15, 2008, “Lewin Group Analysis of ‘Health Care for America'”

As I mentioned in my last comment, I had not done an analysis of the full Lewin Group report but had taken only a quick look to pull out some of the numbers to see whether insurance under the proposal would be affordable.

In the calculation I added to the 6 percent payroll tax a premium of $670 per month (for a two-parent family at 400 percent of the federal poverty level). That was incorrect since that is the premium that non-workers would pay. The correct premium for a worker whose employer is paying the payroll tax would be $200 for a two-parent family at 300 percent of the federal poverty level. Obviously my quick look was too quick.

The calculations are revised for a two-parent family at 300 percent of the federal poverty level or $63,600 (the income level at which the premium is fully phased in). A family that used no medical care would be directly responsible for the $2400 premium plus indirectly responsible for $3816 in payroll taxes, or a total of $6216. That is 9.2 percent of their total income of $67,416 ($63,600 plus the employer payment of $3816 on the employee’s behalf). If they also had out-of-pocket expenses of $4770 (capped at 7.5 percent of $63,600 in direct income) that would be 16.3 percent of their total income of $67,416.

For non-workers, premiums are fully phased in at 400 percent of the federal poverty level or $84,800. For a two-parent family the annual premium would be $8040 or 9.5 percent of their income. If they too had out-of-pocket expenses of $5000 (plan cap on cost sharing) that would total 15.4 percent of their income.

When the average premium for employer-sponsored coverage is already over $12,000 per year, these family payments of $6216 and $8040 seem low. In fact, for an individual, the report states, “We estimate average enrollee costs in Health Care for America would be about $3250 compared to $4230 under a private insurance product in 2007.”

Does that seem reasonable? They state, “Health Care for America premiums would be lower than comparable private insurance due to lower provider payment rates, administrative costs and low-income subsidies.” The low-income subsidies do not apply to the two examples above, both middle-income families. Although they do discuss administrative savings in the report, it is likely that the amount is much smaller than they suggest because they fail to recover much of the waste inherent in a multi-payer system. And the lower provider payment rates? I’ll let you think about that one.

I do wish to express my profound apologies for having used incorrect numbers in my last message. It is important that we make every effort to maintain full credibility in our dialogue. But even the corrected numbers still pose significant problems.

It reminds me of the mathematician, the accountant and the economist who were each asked to solve the problem of two plus two. The mathematician said four, the accountant said four, plus or minus ten percent, and the economist asked, “What do you want it to be?”

Rather than crafting health care financing based on individual plans, whether public or private, it would be far more efficient and equitable to totally separate health care financing from the delivery of health care services. Establish a single, universal risk pool, funded equitably through the tax system, and then use that common pool to fund health care.

Then we would no longer have to tell the economists that we want a plan that provides comprehensive benefits, but it has to have a premium that’s affordable. That may be what we want the plan to be, but we can’t ignore the simple math behind the program.

Finally, I wish to express my profound admiration and respect for the individuals supporting the “Health Care for America” proposal. They share precisely the same goal as ours – comprehensive, high-quality, affordable health care for everyone. With the most noble of intentions, they have crafted a proposal that they believe meets the test of political feasibility while accepting what they would hope to be only temporary, modest compromises on the path to reform.

Our only substantial difference is that we believe that we should not begin from a position of compromise. The private insurance industry has to go.

State plan could work in Kansas

Letters to the Editor
The Capital-Journal (Kansas)
Friday, February 15, 2008

The Legislature has a chance to do it right on the first try.

Actuaries from Arizona presented to the Kansas Health Policy Authority a model of health care reform that provides health insurance for all Kansans and at a cost savings of $800 million over the other four plans considered by KHPA. The Legislature should study this transformative and pioneering plan.

Imagine a Kansas where mothers and fathers go to sleep at night at without the worry of how they will provide health care for their children. Imagine a Kansas where all adults know they will get the health care they need regardless of their economic status.

The plan is a single-payer plan and involves the state becoming the insurance company for all Kansans.

It is a given that many Kansans, including myself, have reservations about turning something as important as health care over to the government.

At the same time, government protects our citizens and fights our wars. It builds our highways and provides subsidies to farmers to ensure a steady supply of food. Why should health care be singled out as the one area where government shouldn’t be a partner?

Under a single-payer plan, more of the health care premium dollars go toward medical care itself. Under a state plan, premium dollars would remain in Kansas. Those dollars could serve as an important economic stimulus to Kansas during a time of recession.

IRA STAMM
Topeka, KS

Asking about single-payer for Massachusetts

By Dr. Susanne King
Berkshire Eagle
Friday, Feb 15, 2008

I often talk with people about health care reform, advocating for single-payer health care as the only answer to problems that include 47 million uninsured people in the United States, and an even greater number of underinsured; the economic pressure on businesses; and the rising costs of health care for our country, states, towns and individuals. Here are the questions people most frequently ask.

1) What is single-payer health care?

“Single-payer” refers to the administration of the health care funds by one payer, rather than the current multiple insurance companies. This payer could be either the state or the federal government. Every other industrialized country in the world has a single-payer system.

2) Is this socialized medicine?

No, because hospitals would still be privately owned, rather than owned by the government, and doctors would still be in private practice. “Single-payer” refers to the taking in and paying out of the health care dollars, which would replace the current role of private insurance companies. Traditional Medicare is a single-payer system that has been in place for many years.

3) Doesn’t Medicare have big problems?

Traditional Medicare has worked very well for patients, and they have been happy with it. However, the intrusion of private insurance companies into the administration of Medicare, first with the introduction of private HMOs in the 1980s, and then by President Bush with subsidies to the insurance companies for drug plans, has wrought havoc with the program.

The insurance companies now see Medicare as a cash cow, creating an economic burden on the program, to the tune of billions of dollars per year. Subsequently payments to doctors, the actual providers of care, have been cut.

4) Can we afford single-payer, if that means covering 47 million uninsured people?

We already pay enough for comprehensive coverage for everyone. We just don’t get coverage for everyone, because 31 percent of our health care spending goes for administration through the patchwork of private for-profit insurance companies. Potential savings from eliminating the waste and astonishing profits of insurance companies (like Massachusetts’ Blue Cross/Blue Shield’s 2006 compensation of over $16 million to its retiring CEO William Van Faasen), has been estimated at $350 billion per year.

5) Won’t there be waiting lines or rationing with single-payer?

The United States currently rations care based on ability to pay, and 18,000 Americans die every year because they lack health insurance. Canada has a single-payer system, and their waiting times for care are shorter than commonly believed. In 2005, the median wait for specialists or elective surgery was four weeks. Canadians live longer and are more satisfied with their health care than Americans, while paying half as much per person.

6) Won’t our aging population break the bank in a single-payer system?

Japan and Europe both have a higher percentage of elderly citizens, yet they spend much less on health care than we do, and have better outcomes. Universal access through a single-payer system prevents more advanced stages of illness, and will pay for long-term care rather than costly hospitalization.

7) Some people like their insurance; why should they change?

Our current system is tied to employment; people change or lose jobs, which disrupts their coverage. Others find their coverage fails when they get sick: 75 percent of the one million Americans experiencing medical bankruptcy each year were insured when they got sick. And insurance premiums go up by double digits every year, for policies that cover less and less.

8) How would single-payer be financed?

Currently about 60 percent of our health care system is financed by public money (our taxes), 20 percent by private employers, and 20 percent by individuals. With a state or national single-payer health program, the public money would be retained. There would be a payroll tax on employers (approximately 7 percent) and an income tax on individuals (approximately 2 percent). The payroll tax would replace all other employer expenses for employee health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any other out-of-pocket payments.

For the vast majority of people, a 2 percent income tax is less than what they now pay for insurance premiums and out-of-pocket payments such as co-pays and deductibles, particularly for anyone who has had a serious illness or has a family member with a serious illness. Many small employers now have to pay 25 percent or more of payroll for health insurance, and large employers now pay roughly 8.5 percent. Everyone would have more comprehensive coverage: in addition to medical care and drugs, benefits would include mental health care, dental care, and long-term care.

9) Who would run a single payer plan?

It is a myth that with national health insurance the government will be making the medical decisions. The government would only be the administrator of the health care funds.

In a publicly financed, universal health care system, medical decisions are left to the patient and doctor, and the public has a say in how the system is run. Cost containment measures will be publicly managed at the state level by an elected and appointed body that represents the people of that state. This body, in consultation with medical experts in all fields of medicine, will decide on the benefit package, negotiate doctor fees and hospital budgets, and be responsible for health planning and the distribution of expensive technology. Right now, insurance companies make many health care decisions behind closed doors, and their interest is in profits, not our health care.

10) Won’t doctors dislike a single-payer system?

Most doctors are very dissatisfied with the current system, because of its administrative burden, and because insurance companies create hurdles to providing care doctors think their patients need. Physicians would like to make medical decisions with their patients, without the intrusion of the profit-motivated insurance companies. In addition, doctors now provide care for which they don’t get reimbursed, when patients are unable to pay because they are uninsured or underinsured. More and more physician groups are supporting single-payer. Physicians for a National Health Program now has 14,000 members.

11) How would we get to a single payer system?

There are bills in the state legislatures and in Congress. Single-payer legislation for our state is the Massachusetts Health Care Trust, Senate bill 703. Federal legislation is HR 676, now supported by 88 congressmen, including Rep. John Olver.

In Canada, single-payer health was introduced province by province, rather than at the national level. Support for single-payer health care is increasing as people learn about the benefits of this solution for our broken health care system.

If you wish to learn more, visit the Web sites www.pnhp.org, www.masscare.org, or www.sickocure.org

Susanne L. King, M.D., is a Lenox practitioner.