PNHP

10 Questions: More About Health Care Katie Couric

pnhpf3a

10 Questions: More About Health Care Katie Couric

CBS
August 17, 2007

Right now, in the heat of August, we’ve decided to take the temperature of health care in America. It promises to be a big issue in the ’08 election, but often we don’t start learning about its intricacies until faced with serious health issues of our own. Then, the medical bills start piling up on the kitchen table, and you just don’t know where to begin.

Well, to get a handle on health care in this country, we fired off 10 Questions to two experts: On the right we had Robert Moffit, who’s the director of the Heritage Foundation’s Center for Health Policy Studies. We posted his answers last week.

(Public Citizen)

Now we have Dr. Sidney Wolfe, the director of Public Citizen’s Health Research Group. Public Citizen is a more liberal-leaning consumer advocacy organization. He’s testified before Congress numerous times — including just last month, on Oxycontin — and he edits WorstPills.org, a website that’s updated monthly and serves as a sort of second opinion on prescription drugs.

One thing we found interesting: when we asked the two men our first question — to name the one thing they’d change about the health care system — they both began with the exact same words: The financing. And then they diverged.

1. If you could change ONE thing about our health care system, what would that be?

The financing. Instead of hundreds of profit-seeking health insurers, money should be collected and bills paid by a single government payer.

At present, insurance company overhead and the paperwork that inflicts on doctors and hospitals wastes more than $350 billion a year — money that could cover the uninsured and eliminate co-payments and deductibles for those who currently have partial coverage. Progressive income taxes would be paid, just as we now do for other financially socialized benefits such as libraries, the police, schools, Social Security and, in the health area, for Medicare. Because of the huge administrative savings, a single payer system could cover everyone without expending any more dollars.

2. Most people agree that the costs are out of control. What can be done about that?

By far, the fastest growing element of cost is wasteful health administration. The number of doctors increased 2.5-fold from 1970 to 2005, largely in proportion to growth in the population. The number of registered nurses grew a bit more slowly. But the number of health administrators increased 26-fold during the same interval.

Another rapidly growing cost is the price of prescription drugs. Unlike all other developed countries where prescription drug prices are negotiated or controlled — and as we do for the Department of Defense and for the Veterans’ Administration — the costs for everyone else in this country are largely out of control and, for many, unaffordable.

The single payer approach could cut paperwork costs drastically, and force drug prices down.

3. What works in our system? What doesn’t?

Our system of medical education and our medical research are as good as most places in the world. But, because of the enormous expense of U.S. medical schools, much higher than most countries in the world, many students from poorer economic backgrounds are less likely to go into medicine.

The success of U.S. medical research would not be possible without the huge public subsidy through the NIH, now funded at more than $28 billion a year, another example of a progressively taxed, financially socialized benefit for everybody.

As discussed above, the current multiple payer financing is unaffordably wasteful and forces a larger and larger proportion of the $2 trillion we spend on health each year to fund people who are not, in any remote way, delivering medical care. They are not doctors, nurses, pharmacists or other health care providers but, in many cases, health care deniers whose job it is to fight with each other (insurance administrator vs. hospital administrator or doctor’s office administrator) to deny payments or even coverage for needed health services.

4. People come to this country from all over the world and get great medical care. But so many Americans slip through the cracks. What can be done to close this gap?

In what has been described as medical tourism, the United States, with its large pharmaceutical and medical-device industries and high-tech hospitals, has traditionally been a destination for patients, primarily those affluent enough to pay out-of-pocket, or those who have generous insurance coverage that extends beyond their countries of origin.

But recent years have also seen a flow in the opposite direction, with large numbers of American patients traveling abroad in search of less expensive and often more luxurious health care, frequently surgery.

The problem of Americans “slipping through the cracks” because of being uninsured or underinsured can only be dealt with by providing universal health coverage for all people in this country.

5. We hear a lot about the number of uninsured Americans. Just how many are there?

At the time of a government survey in 2006, about 43.6 million people in the United States, or 14.8 percent of the population, had no health insurance. But about 54.5 million people in the country, or 18.6 percent of the population, had no insurance for at least part of 2006.

An even larger problem is the growing number of people who are underinsured. Illness and medical bills cause about half of all bankruptcies, and three-quarters of these people forced into medical bankruptcy had health insurance coverage — at least when they first became ill. In many cases people cannot afford policies with optimal coverage, or they choose a policy with a relatively low premium but a massive deductible, often thousands of dollars a year. Such inadequate coverage keeps them from seeking care because of the unaffordable out-of-pocket expenses.

Conservative estimates are that about 100 million people in this country — one third of our population — are either uninsured or underinsured.

6. What’s the lowdown on managed care? HMOs? Single payer?

In its origins, managed care was dominated by excellent not-for-profit HMO models such as Group Health Cooperative of Puget Sound, located in Seattle. The market is now dominated by large, non-local, for-profit managed care companies, whose quality of care has been shown to be significantly worse than that of the non-profits.

Single payer means the government collects the money and pays the bills. By having all people in this country covered by a single payer health system, not just those on Medicare, our current expenditures for health — in excess of $2 trillion a year — could go much further and all but eliminate the serious problem of one out of three people being uninsured or underinsured.

In Canada, for instance, people can choose any doctor or hospital they wish to go to, unlike the increasingly restricted lists of doctors that managed care companies in this country allow.

7. What role should the government play in providing Americans with health care? What role should the marketplace play?

The government should guarantee that everyone in this country has health insurance by collecting the money and paying the bills, cutting out the pick-pockets in private industry.

The role of the marketplace — and this includes for-profit health service entities such as HMOs, hospitals, nursing homes and kidney dialysis centers — has been succinctly stated by my colleagues, Harvard professors and doctors Steffie Woolhandler and David Himmelstein. They co-founded Physicians for a National Health Program, which now includes more than 14,000 physicians, medical students and health professionals who support single payer health insurance.

In an article eight years ago in the New England Journal of Medicine, they wrote: “In our society, some aspects of life are off-limits to commerce. We prohibit the selling of children and the buying of wives, juries, and kidneys. Tainted blood is an inevitable consequence of paying blood donors; even sophisticated laboratory tests cannot supplant the gift-giving relationship as a safeguard of the purity of blood. Like blood, health care is too precious, intimate, and corruptible to entrust to the market.”

8. Is there a model for a health care system that you think works, that we might model our reformed system after?

The model we adopt for our single payer health care system can be crafted from the best elements of existing systems in the many countries, such as Canada and France, that already provide universal health care. All of these countries spend far less per capita than we do in this country, and everyone is covered.

The best models eliminate private health insurers, require that hospitals and other health institutions be run on a non-profit basis, and exercise strict control over the pharmaceutical industry. The multiplicity of state health insurance initiatives, with the exception of California state senator Sheila Kuehl’s bill, which advocates a single payer, are doomed to fail. They are thinly disguised versions of the failing system we have now, one dominated by wasteful private health insurers.

9. The baby boomers are now starting to retire, and people question whether Medicare will be able to handle them. Will it?

At present, Medicare is wasting about ten billion annually overpaying private Medicare HMOs, which have been touted by pro-market enthusiasts as the solution to Medicare’s problems. Doctors and hospitals drain tens of billions more for unnecessary, but profitable, procedures, drugs etc.

For instance, thousands of kidney dialysis patients have been given dangerous overdoses of epoiten because dialysis centers and drug companies have made huge profits from this drug. Similarly, about half of all cardiac stents are unnecessary, leaving the patient no better off, but gaining the hospital about $20,000 per patient. Eliminating HMOs from Medicare, reorienting Medicare payments to minimize incentives for over-treatment (as well as under-treatment), and encouraging primary and preventive care would go far to assuring the long-term viability of the program.

Assuring coverage for people under 65 would also save Medicare money. When the uninsured turn 65, their Medicare bills are far higher because they failed to get timely care.

Financing Medicare by a much more progressive tax, and improving Medicare coverage to eliminate current co-payments and gaps in coverage for prescription drugs would also broaden support for the program. Canada’s universal coverage program, which is also called Medicare, shows that national health insurance is the best solution to rising costs.

When Canada’s program began, in 1971, they spent the same proportion of GDP on health care that we did. Now they spend about 40% less.

10. What role will the health care issue play in the election? And is there a political candidate in this broad field who you think has the right idea?

We can not only hope that health care plays a major role in the coming presidential election but also that the ideas put forth are more progressive than those currently being espoused by all of the so-called leading candidates. Representative Dennis Kucinich is the only candidate with the guts and honesty to tell it like it is, instead of pretending that versions of our failed system can work. His support for the current single payer House Bill (HR 676) sets him apart from all the other candidates.

Was your $100 in drug marketing worth it?

A Decade of Direct-to-Consumer Advertising of Prescription Drugs

By Julie M. Donohue, Ph.D., Marisa Cevasco, B.A., and Meredith B. Rosenthal, Ph.D.
The New England Journal of Medicine
August 16, 2007

Evidence suggests that direct-to-consumer advertising of prescription drugs increases pharmaceutical sales and both helps to avert underuse of medicines and leads to potential overuse. Concern about such advertising has increased recently owing to the withdrawal from the market of heavily advertised drugs found to carry serious risks.

We examined industry-wide trends in spending by pharmaceutical companies on direct-to-consumer advertising and promotion to physicians during the past decade.

Total spending on pharmaceutical promotion grew from $11.4 billion in 1996 to $29.9 billion in 2005. Although during that time spending on direct-to-consumer advertising increased by 330%, it made up only 14% of total promotional expenditures in 2005.

http://content.nejm.org/cgi/content/full/357/7/673

Comment:

By Don McCanne, MD

The $30 billion spent by the pharmaceutical firms in promoting their drugs amounts to an astonishing $100 per each man, woman and child in the United States. That is a lot of money that must be built into the price of drugs. Are we receiving any value for this investment?

Direct-to-consumer marketing does result in patient preferences for drugs that are much more expensive because they are on patent, even though established generic drugs may be therapeutically equivalent or may be an even more appropriate choice. Newer patented drugs actually may turn out to be an inferior choice after post-marketing surveillance demonstrates a greater incidence of untoward events. Direct-to-consumer marketing is a hindrance rather than a help is selecting appropriate treatment.

But drug companies spend far more on promoting their products to physicians. From the perspective of better health care, is that money well spent? Many physicians contend that they always select drugs that are the best choices for their patients, and that they would never be influenced by the marketing of pharmaceutical firms. Sadly, that is not always true. Marketing programs do increase physician prescribing of newly patented products, even when there is a lack of evidence of the superiority of the new product. When a physician uses drug samples to start a patient on a treatment program, he/she has taken the pharmaceutical firm’s bait. And that memo that may stay around for months or years, written on a free scratch pad, will keep the not-so-subliminal name in front of the physician perhaps indefinitely. As with direct-to-consumer marketing, the money spent on promotion to physicians also produces a hindrance rather than a help in the selection of a drug treatment.

The decisions on whether to use drugs and which ones to use should be based strictly on best medical practices rather than on the most effective marketing. Under a national health insurance program, special efforts should be made to keep physicians informed on best practices. Also, negotiations with pharmaceutical firms should result in prices based on legitimate expenses plus fair profits.

One of the first things to go should be that $100 apiece, on average, that we are spending for harmful marketing that is hindering our quest for optimal health care in America.

Doctors, Nurses Challenge Edwards to Endorse Real Reform

For Immediate Release
August 16, 2007

Contacts:
PNHP- Todd Main, 312-782-6006
CNA/NNOC- Charles Idelson, 415-559-8991

Iowa Ads Call for Leadership on Guaranteed Health Care for All

Physicians for a National Health Program and the California Nurses Association/National Nurses Organizing Committee today launched the first in a series of broadcast and internet ads in Iowa challenging the leading Democratic candidates to take a more meaningful stand on health care by endorsing a single-payer style, guaranteed healthcare for all, system.

In the first ad, which begins running this morning, a cardboard stand-in for former Sen. John Edwards is asked “Why are we wasting thirty-one cents out of every health care dollar on administrative expenses?” by a small businessman. “Eliminate the middleman, make our businesses more competitive globally, and this country could afford health care for everyone.”

“We need real reform that cuts out the profiteering insurance companies and drug companies and creates a single-payer program guaranteeing healthcare for ALL Americans. Where’s the leadership on this, Senator Edwards?” the businessman asks.

The ad calls on viewers to “let the Democratic candidates for president know that real leadership on healthcare doesn’t mean just being better than the Republicans.”

Created by Bill Hillsman and North Woods Advertising, the ad can be seen on YouTube http://www.youtube.com/watch?v=XNJTxRf6x3Q or at www.pnhp.org or at www.guaranteedhealthcare.org.

The series of ads coincide with the Iowa appearance of the Democratic Presidential candidates in several forums this week, culminating with a joint appearance Sunday on the ABC’s This Week with George Stephanopoulos.

CNA/NNOC President Deborah Burger, RN explains that a theme of this ad is “to encourage Sen. Edwards, who extensively talked about healthcare, to embrace the only approach that will actually solve our national healthcare nightmare, a comprehensive single-payer plan, as in HR 676, a form of an improved Medicare for all, as exists in all other Western countries.”

In a Presidential forum sponsored by the AFL-CIO in Chicago last week, Sen. Edwards himself asked, “when are we going to actually stand up to these drug companies, these insurance companies? We’ve got to stop playing nice. We have to beat these people.”

“The public will support a champion of real healthcare reform,” says PNHP co-founder Quentin Young, MD. “Yet Edwards’ plan, leaving the insurance companies in place, fails to seize this opportunity. The candidate who embraces single payer may well win the nomination.”

What Businesses Have to Gain from Single-Payer Healthcare

American companies and small businesses in particular have much to gain from a single-payer reform, such as HR 676, say PNHP and CNA/NNOC.

* U.S. employers are at a huge competitive disadvantage with businesses based in Canada, Europe, or any other country with a national or single-payer healthcare system. Detroit automakers, for example, cite annual costs of about $12 billion to provide health benefits for current and former employees – money their competitors in Europe, Canada, and Asia do not have to spend.

* Skyrocketing costs, especially in insurance and drug company charges, are jeopardizing both business owners and employees.

* Premiums for healthcare coverage have risen 87% since 2000, placing a huge burden on those employers who provide health benefits for their employees. Many have felt forced to respond to their increased healthcare costs by reducing benefits for their employees or substantially shifting costs to their employees. A consequence is that rising costs have dramatically increased health insecurity for millions of Americans with insurance. A recent Wall Street Journal/NBC poll found that rising healthcare costs are the top domestic concern for voters.

* From coast to coast, employer efforts to cut healthcare costs have sparked over 90% of U.S. strikes and contract battles.

* Employees would not have to delay obtaining needed care due to spiraling costs, avoiding illnesses that can lead to greater health complications and work absences. For businesses, this translates into a healthier workforce and increased productivity.

* Business owners themselves also have substantial healthcare worries for their families, including threats of denial of care due to pre-existing conditions or loss of insurance after even minor medical problems. Like other Americans, many small business owners are one sickness, accident, or injury away from financial ruin. Single-payer is the only reform that guarantees health security for their families.

Medicare Advantage plan in receivership

SunCoast Physicians Health Plan

SunCoast Physicians Health Plan is a new Medicare Advantage HMO that has been built on traditional medical values, when medicine was about caring for patients not managing them.

Liquidation Order Entered Against SunCoast Physicians Health Plan, Inc.

On Friday, August 10, 2007, SunCoast Physicians Health Plan, Inc. (“SunCoast”) was ordered into receivership for purposes of liquidation by the Second Judicial Circuit Court in Leon County, Florida. The Florida Department of Financial Services is the court appointed Receiver of SunCoast.

http://www.suncoastphp.com/

Comment:

By Don McCanne, MD

Congress and the administration established the private sector Medicare Advantage plans to compete with the traditional Medicare program, arguing that the market is always more efficient than the government. Just to be certain that these private plans were successful, they were given an average of 12 percent more funds than were allocated for traditional Medicare. That wasn’t enough of a buffer for this plan to avoid receivership.

There is now a proposal before Congress to eliminate the excess payments and allow these private plans to truly compete with Medicare on a level playing field. If that passes, will we be seeing more plans go into receivership, or will they just walk away?

Open doors to medical care to all; adopt single-payer system in U.S.

Dr. Laurence Jacobs
Rochester Democrat and Chronicle
Guest essayist

(August 14, 2007) — The movie Sicko has stimulated discussion of health care costs and access in the United States. Our patchwork nonsystem of competing health care insurances, with its profit motive driving denial of care and of physician choice, is clearly failing. It needs to be replaced by a more rational and humane method of assuring universal coverage and care for all our citizens.

Despite spending more per capita on health care than any other nation in the world, we lag behind in infant mortality and life expectancy rates. It is disgraceful that the richest nation on the planet is the only industrialized nation that fails to provide health care to all its citizens. We have 47 million uninsured, and more millions partially insured, or insured for only part of the time.

More than half of all personal bankruptcies are precipitated by the enormous cost of serious illness, despite the fact that more than two-thirds of these unfortunate individuals actually had health insurance prior to becoming ill.

Most Americans believe that health care should be available to all, but that is far from the case. Many uninsured people defer or neglect health care, including cost-effective preventive care, for fear of incurring debt beyond their ability to repay. As a result, early illness may become incurable; yearly an estimated 18,000 uninsured Americans die needlessly in this country.

The best way to fix this unacceptable situation is to shift to a single-payer health care system. Overhead in the private health insurance sector is estimated to be nearly 33 percent. Medicare overhead is less than 3 percent. The $350 billion in savings that would occur by eliminating the profit motive and moving to a single-payer system, like Medicare for all, would allow us to insure our entire population.

Why is overhead so high in the private sector? Just think of all the clerical and administrative staff necessary to run the incredibly complex system of deductibles, co-pays, denials and determination of who is eligible for what coverage and when. And then there is the issue of multimillion-dollar salaries for the executive echelon in the industry. Is this the way our health care dollars should be spent?

Many are concerned about government involvement in health care financing; one hears supporters of the present arrangements solemnly pronounce fear of “socialized” medicine. In a single-payer system, they predict, care will be rationed and the government will dictate who gets care and how. This fear-mongering is simply untrue.

Further, we already have rationing of care (based on ability to pay), and interference in the delivery of health care, by insurance companies that limit care based on criteria that they establish and interpret.

What I, and the other 15,000 members of Physicians for a National Health Program propose is a centralized system of payment, not a system for the provision of care.

Under a single-payer system, physician choice would be maintained, and decisions made in the traditional fashion, between physicians and patients. The driving force would be patient welfare, not profit. Such a system would dramatically reduce physician paperwork and frustration as well, and might help stem the rising tide of physicians leaving practice.

Politicians justifiably fear being attacked by the health insurance industry on the topic of a single-payer health system. But this topic is so important to so many of us that fear of industry reprisal or attack must be swept aside, and a rational plan developed to phase out our present inhumane and costly patchwork for a single-payer system. This is the best way to assure access to health care for all our citizenry and improve our population’s health. It is also the moral and right thing to do.

Jacobs is professor of medicine emeritus, University of Rochester, and vice chairman, Finger Lakes Chapter, Physicians for a National Health Program.

Defining success for Illinois' All Kids

A Race to the Top: Illinois's All Kids Initiative

Prepared by Teresa A. Coughlin and Mindy Cohen of The Urban Institute
Kaiser Commission on Medicaid and the Uninsured
August 2007

In the summer of 2006, Illinois joined several other states in advancing health care reform by launching the nation’s first universal coverage program for children. Called “All Kids,” the initiative builds on the state’s Medicaid and State Children’s Health Insurance Program (SCHIP) programs but is funded exclusively with state funds. The program offers coverage to all uninsured children, regardless of income, health status or citizenship.

As of April 2007, about 50,000 children have enrolled in the expansion part of the All Kids initiative. About half are in households with income less than 200 percent of the FPL. Many of these are immigrant children who do not yet qualify for Medicaid and SCHIP because of program citizenship and immigration requirements. Most of the remaining new enrollment has occurred in the low-to moderate-income groups but some children in the higher income groups have also enrolled. About 100 children with $100,000 or greater family income have enrolled. Prior to the All Kids expansion, the state estimated that there were about 250,000 uninsured children across all income groups in Illinois.

By all accounts and by enrollment numbers, program outreach for All Kids has been a success. In large part, this success was attributed to the considerable campaign the state undertook to market All Kids, one that used a range of innovative strategies. The state’s streamlined application and follow-up processing, which includes a new online option, also likely contributed to the program’s enrollment success. Another likely important factor is the state’s decision to incorporate the expansion directly into its Medicaid and SCHIP programs and then market all under the single umbrella name of All Kids. In short, the outreach, the application process and the integrated program, make All Kids customer friendly and easy to understand.

Materials released by the governor’s office when the proposal was unveiled state that All Kids was designed to provide access to “good, affordable,” and “comprehensive” coverage to the state’s more than 250,000 uninsured children.

In terms of enrollment, All Kids has been a great success: Implemented July 2006, the initiative had a goal of expanding coverage to 50,000 children in the first year. Within nine months of implementation (April 2007), it had already reached that enrollment target.

http://www.kff.org/uninsured/upload/7677.pdf

Comment:

By Don McCanne, MD

Illinois’ All Kids was developed and promoted as a program that would provide health insurance coverage for all children in the state. A goal was set to cover 50,000 (one-fifth) of the uninsured children within the first year. This report celebrates the success of this program in that it achieved this target in only nine months. But is a celebration really warranted?

Before answering that, it is important to acknowledge that insuring 50,000 children who previously had no coverage is a good thing. But incrementalism is a bad thing when another 200,000 children are left without coverage.

When this program was established, it was very clear that there were many design flaws that made it virtually impossible to extend coverage to all uninsured children. Some of these flaws were covered in a Quote of the Day message over a year ago (link below). Although the current report celebrates the “race to the top,” a careful reading of the report confirms that the design flaws had their fully predictable negative impacts. In fact, it is clear from reading this report that it is improbable that coverage would ever be expanded to much more than one-fifth or one-fourth of the population of uninsured children.

Although it is now only one year into the program, it is safe to say that it is a failure. Establishing an artificial goal of accomplishing only one-fifth of the intended results does not entitle you to declare success merely because you reached that deficient goal.

It is important to understand that the failure was in the design of the program. Health policy science has advanced to the degree that outcomes of most policies are quite predictable. It is an egregious error on the part of politicians and the policy community to proceed with programs with fully predictable adverse results. To say that we should just go ahead with this program anyway and see how it works is health policy malpractice.

Illinois will never insure all of the children until they enact a program that results in automatic and permanent enrollment of every single child.

Likewise we will never insure everyone in the United States until we enact a program that results in automatic and permanent enrollment of every single individual. Those in the single payer reform movement can describe the policies that would make that happen. And it wouldn’t be necessary to test it them see if they would work.

qotd: Illinois’ dubious claim of first to cover all kids:
https://pnhp.org/news/2006/june/illinois_dubious_cl.php

Defining success for Illinois’ All Kids

A Race to the Top: Illinois’s All Kids Initiative

Prepared by Teresa A. Coughlin and Mindy Cohen of The Urban Institute
Kaiser Commission on Medicaid and the Uninsured
August 2007

In the summer of 2006, Illinois joined several other states in advancing health care reform by launching the nation’s first universal coverage program for children. Called “All Kids,” the initiative builds on the state’s Medicaid and State Children’s Health Insurance Program (SCHIP) programs but is funded exclusively with state funds. The program offers coverage to all uninsured children, regardless of income, health status or citizenship.

As of April 2007, about 50,000 children have enrolled in the expansion part of the All Kids initiative. About half are in households with income less than 200 percent of the FPL. Many of these are immigrant children who do not yet qualify for Medicaid and SCHIP because of program citizenship and immigration requirements. Most of the remaining new enrollment has occurred in the low-to moderate-income groups but some children in the higher income groups have also enrolled. About 100 children with $100,000 or greater family income have enrolled. Prior to the All Kids expansion, the state estimated that there were about 250,000 uninsured children across all income groups in Illinois.

By all accounts and by enrollment numbers, program outreach for All Kids has been a success. In large part, this success was attributed to the considerable campaign the state undertook to market All Kids, one that used a range of innovative strategies. The state’s streamlined application and follow-up processing, which includes a new online option, also likely contributed to the program’s enrollment success. Another likely important factor is the state’s decision to incorporate the expansion directly into its Medicaid and SCHIP programs and then market all under the single umbrella name of All Kids. In short, the outreach, the application process and the integrated program, make All Kids customer friendly and easy to understand.

Materials released by the governor’s office when the proposal was unveiled state that All Kids was designed to provide access to “good, affordable,” and “comprehensive” coverage to the state’s more than 250,000 uninsured children.

In terms of enrollment, All Kids has been a great success: Implemented July 2006, the initiative had a goal of expanding coverage to 50,000 children in the first year. Within nine months of implementation (April 2007), it had already reached that enrollment target.

http://www.kff.org/uninsured/upload/7677.pdf

Comment:

By Don McCanne, MD

Illinois’ All Kids was developed and promoted as a program that would provide health insurance coverage for all children in the state. A goal was set to cover 50,000 (one-fifth) of the uninsured children within the first year. This report celebrates the success of this program in that it achieved this target in only nine months. But is a celebration really warranted?

Before answering that, it is important to acknowledge that insuring 50,000 children who previously had no coverage is a good thing. But incrementalism is a bad thing when another 200,000 children are left without coverage.

When this program was established, it was very clear that there were many design flaws that made it virtually impossible to extend coverage to all uninsured children. Some of these flaws were covered in a Quote of the Day message over a year ago (link below). Although the current report celebrates the “race to the top,” a careful reading of the report confirms that the design flaws had their fully predictable negative impacts. In fact, it is clear from reading this report that it is improbable that coverage would ever be expanded to much more than one-fifth or one-fourth of the population of uninsured children.

Although it is now only one year into the program, it is safe to say that it is a failure. Establishing an artificial goal of accomplishing only one-fifth of the intended results does not entitle you to declare success merely because you reached that deficient goal.

It is important to understand that the failure was in the design of the program. Health policy science has advanced to the degree that outcomes of most policies are quite predictable. It is an egregious error on the part of politicians and the policy community to proceed with programs with fully predictable adverse results. To say that we should just go ahead with this program anyway and see how it works is health policy malpractice.

Illinois will never insure all of the children until they enact a program that results in automatic and permanent enrollment of every single child.

Likewise we will never insure everyone in the United States until we enact a program that results in automatic and permanent enrollment of every single individual. Those in the single payer reform movement can describe the policies that would make that happen. And it wouldn’t be necessary to test it them see if they would work.

qotd: Illinois’ dubious claim of first to cover all kids:
https://www.pnhp.org/news/2006/june/illinois_dubious_cl.php

World’s Best Medical Care? (New York Times)

World’s Best Medical Care?

Editorial
The New York Times
August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

http://www.nytimes.com/2007/08/12/opinion/12sun1.html?pagewanted=all

Comment:

By Don McCanne, MD

We have the money. We should have “the best health care system in the world.” But building on mediocrity will only bring us more mediocrity at ever greater levels of spending.

We are already using the tax system to pay for two-thirds of our health care (Reinhardt). But now we need to do what every other nation has done: establish public policies that improve the allocation of our health care resources. That means that we must remove the private stewards of our health care funds as they have proven themselves to be utterly incompetent.

If we are going to raise our health care system above the level of mediocrity, we simply have to place our public funds under the control of our own public stewards – through a program of national health insurance.

Uwe Reinhardt quote on two-thirds of health care spending through the government:
https://www.pnhp.org/news/2006/december/private_plans_pay_so.php

World's Best Medical Care? (New York Times)

World's Best Medical Care?

Editorial
The New York Times
August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

http://www.nytimes.com/2007/08/12/opinion/12sun1.html?pagewanted=all

Comment:

By Don McCanne, MD

We have the money. We should have “the best health care system in the world.” But building on mediocrity will only bring us more mediocrity at ever greater levels of spending.

We are already using the tax system to pay for two-thirds of our health care (Reinhardt). But now we need to do what every other nation has done: establish public policies that improve the allocation of our health care resources. That means that we must remove the private stewards of our health care funds as they have proven themselves to be utterly incompetent.

If we are going to raise our health care system above the level of mediocrity, we simply have to place our public funds under the control of our own public stewards – through a program of national health insurance.

Uwe Reinhardt quote on two-thirds of health care spending through the government:
https://pnhp.org/news/2006/december/private_plans_pay_so.php

Health-care system: Single payer is the way to go

By Hedda Haning
The Charleston Gazette
August 12, 2007

Three commentaries in the Aug. 5 Sunday Gazette-Mail related to the costs of medical care in the United States — one on children’s coverage, one on the negative effects on business and one reporting the negative effects of privatization on Medicare. But the most stunning demonstration that the system is broken was the article describing a Florida couple receiving nursing home care in India.

In the 1930s FDR’s original Social Security legislation included medical coverage, modeled on European programs of the time. The AMA fought the medical part vigorously. Not wanting to risk his entire program, FDR removed medical insurance from the plan.

During World War II, wages were controlled, and employers, trying to attract workers in a tight labor market, added medical insurance to wages as an inducement. The strategy worked. Thus was medical insurance linked to employment. It was really a pragmatic accident of the times, rather than the result of studious deliberation.

Which brings us to where we are now. Because of major advances in science and technology, medicine has much more to offer us, and it is now an expensive necessity rather than an optional nicety. Many jobs have been outsourced. Few jobs last a lifetime. The labor market is not tight, so employers don’t need benefits to attract workers. The result is that far fewer people have coverage through their work. And the self-employed have always had to finance their own care, all while costs are climbing far faster than inflation.

Co-payments and deductibles raise consumers’ out-of-pocket costs substantially higher. Claims are denied. Many insured do not get the care they need, and the uninsured are totally out in the cold, but often invisible to the community.

Furthermore, as Dr. Dan Foster mentioned, the high cost of privately insured health care is becoming an unsustainable burden for business. Plainly the system that worked in World War II and through the 1980s is not working now.

Contrary to President Bush’s assertion, desperately getting emergency help is not equivalent to having dependable, readily available health care. Everyone agrees we have a problem. The solution is in contention. The favorite approach now is to help Americans buy into private insurance plans.

It is time for a reality check.

Private insurers are in business to make a profit for their stockholders. For most companies, 30 percent of premiums go to administration, marketing and profits. Private insurers have an incentive to hold down their own costs and increase their profits. They have no incentive to hold down subscriber costs or improve subscriber care, both of which would cut into profits.

Perhaps we should use our experience with safety services, schools, libraries and roads to suggest a solution. First, concentrate on care, not insurance. Insurance is only one route toward paying for health care. All health care should be:

* Universal and equitable — the same care available to everyone, including Congress.

* Unaffected by employment status, pre-existing conditions or ability to pay.

* Comprehensive, covering all medically necessary expenses including primary care, medications, procedures, hospitalizations, mental health, dental, nursing home and home health care.

* Non-profit, a regulated public service.

* Totally paid for from tax-supported public funds with no co-payments and no deductibles.

* Portable throughout the United States.

You would continue to choose your own doctor and hospital. The difference is in the payment system. Payments to providers and hospitals would come from a single payer, an agency local enough to be workable, such as representing a single state or a group of states. Without paperwork for each visit, administrative costs would be greatly reduced.

A single system can better assess the application of new technology and quality of care outcomes, and regulate medication quality and cost. Since we would all be in the same boat, we would all have an incentive to fix the problems that will surely arise.

Furthermore, preventive and primary care could become the priority they should be. That would include paying for all children to have routine exams and immunizations.

Most people don’t know that the federal government already pays for two-thirds of health-care costs through programs including Medicare, Medicaid, the military and tax breaks. The federal government already pays — right now — more per capita for health care than other developed nations pay.

Some think that the most important goal is to protect private insurance company profits. That is why the attempt is being made to privatize Medicare in spite of demonstrable increased cost and poorer performance.

You’ve heard the argument against this proposal: “not politically feasible,” which means the insurance and pharmaceutical companies don’t like it.

Yet most primary-care physicians support such a program, as do numerous medically affiliated professionals, unions and non-profit organizations. Doctors in other capitalist countries are quite positive about their own single-payer systems, as are the patients they serve. They do research, develop and use new drugs, and have access to more advanced technology than we do. They have less interference with their medical decisions than our doctors. And their health outcomes are better than ours, all while keeping health care reasonably affordable.

Perhaps it’s un-American? Still polls show that two-thirds of Americans support such a program, even if they have to pay more in taxes to get it, which would still cost less than paying for private insurance. Single payer is the only feasible plan.

Of course there are details to be worked out, but we are in serious trouble here. Other developed countries have succeeded in providing better health care than we do for half the cost. Aren’t we as smart as they are?

Haning is an anesthesiologist and a member of the Mountain State Physicians for a National Health Program.

CMA testimony on Blue Cross

CMA Calls Blue Cross a Leader in Profits, Not Patient Care

California Medical Association
California Physician
August 9, 2007

CMA on Tuesday asked the Department of Managed Health Care to take action against Blue Cross of California for jeopardizing the physician-patient relationship and engaging in unlawful business practices that have reduced patient access to care.

CMA testified at a public hearing in Los Angeles that Blue Cross has violated the promises it made to California patients when it merged with Anthem Health Care in 2004. Since that merger, Blue Cross has consistently increased premiums, while reducing the amount of money spent on patient care. The insurer is now dangerously close to not having enough physicians available to serve the 8.3 million Blue Cross patients in California.

With the consolidation of the health plan industry, both nationally and in this state, competition among the insurance companies has been severely diminished, if not eliminated, much to the detriment of the very individuals these plans promise to serve patients and their treating physicians, CMA said in its written testimony. The turmoil created by Blue Cross has taken its toll on everyone. It must be remembered that it is physicians who provide medical care to patients, not health plans.

DMHC called the hearing to review commitments made by Blue Cross when it merged with Anthem three years ago. DMHC this year alone has initiated 18 enforcement actions against Blue Cross, including multiple fines a significant increase from previous years.

CMA contends that among a vast collection of misdeeds, Blue Cross has:

* reimbursed physicians at unconscionably low levels, at times below the actual cost of care;

* increased consumer premiums at a much higher rate than any other major health insurer, raising rates as much as 10 percent in a single year;

* rescinded authorization and refused to pay for care provided in good faith;

* reduced reimbursement levels without appropriate notice;

* retroactively canceled individual health insurance coverage after policyholders got sick.

For at least a decade, Blue Cross has consistently spent less on medical care than the 85 percent required by law, at the same time raising premiums and increasing profits.

While Blue Cross seems averse to paying physicians fairly and spending adequately on health care, the insurer plans to spend $2 million this year trying to defeat health reform proposals designed to increase access to care in California.

Blue Cross’s misbehavior shows significant signs of diminishing the supply of physicians, already a growing problem in California. CMA and its county component medical societies have received a number of calls from physicians who have determined that they can no longer financially and ethically provide medical care under the dictates of Blue Cross and are being forced to terminate their contracts altogether.

http://www.calphys.org/html/cc482.asp

CMA testimony:
http://www.cmanet.org/upload/bc_testimony_080707.pdf

Comment:

By Don McCanne, MD

Wall Street analysts have continued to praise Blue Cross of California and its parent company (WellPoint) as being leaders in private insurance innovations that have led to stellar performances in the equities markets. Blue Cross/WellPoint has led, and in order to remain competitive, the others (including the non-profits) have followed.

As we reform our system of health care financing, do we really want more of this type of leadership? If not, we’re going to have to let our politicians know, because they’re headed that way.

WHO report on private insurance and cost sharing

What are the equity, efficiency, cost containment and choice implications of private health-care funding in western Europe?

By Sarah Thomson and Elias Mossialos (London School of Economics and Political Science)
World Health Organization
Health Evidence Network
July 2004

The issue

Over the last 20 years the level of private spending on health care has risen in many western European countries, leading to concern about its impact. The main channels of private spending are private health insurance policies and cost-sharing schemes in public health systems.

Findings

Evidence shows that private sources of health care funding are often regressive and present financial barriers to access. They contribute little to efforts to contain costs and may actually encourage cost inflation.

Private health insurance

The role of private insurance in western European health systems is largely determined by the extent of statutory health insurance. The evidence shows that:

* Allowing people to opt out of statutory health insurance threatens its long-term financial stability.

* Relying on complementary private health insurance to protect people against high levels of statutory user charges can increase inequities in access to care between those who can and cannot obtain such coverage.

* Supplementary private insurance increases inequalities of access, particularly where there are no clear boundaries between public and private health care provision.

* Tax subsidies for private health insurance are inefficient – because they distort signals about the real price of insurance and generate transaction costs – and inequitable, as they tend to benefit higher income groups.

* Private health insurers lack efficiency incentives and tend to incur higher administrative costs than statutory health insurance. Publicly-funded systems are generally more successful in controlling cost inflation than mainly privately-funded systems.

* Private health insurance can increase choice for some, but not to the extent that is often suggested, and under certain circumstances it may even restrict choice.

Cost sharing

Cost sharing is widely used in western European health systems to moderate demand and/or raise revenue. However, the theoretical case for cost sharing is weak, particularly when applied to health care arising from referral or prescription. The evidence shows that:

* Cost sharing shifts costs to individuals and leads to significant reductions in the use of health care.

* Cost sharing reduces the use of both appropriate and inappropriate health care, which has negative implications for equity and efficiency.

* Cost sharing is not an effective means of containing costs.

* Differential charges can be used to encourage more cost-effective patterns of health care use.

* Because cost sharing creates financial barriers to access, it should be accompanied by mechanisms to protect heavy users of health care and lower income groups.

* Exemption systems require administrative capacity, may generate significant transaction costs and may limit cost sharing’s ability to raise revenue.

http://www.euro.who.int/document/e83334.pdf

Comment:

By Don McCanne, MD

Even though released three years ago, this primer on private health care funding of Western European countries is especially informative for the dialogue on health care reform now taking place in the United States.

The report demonstrates that both private health insurance and patient cost sharing have a negative impact on equity, efficiency and affordable access to care. Some contend that we have to accept these perversities in order to contain health care costs. But one of the most important findings in this report is that neither is effective controlling cost inflation.

I omitted the policy recommendations that were presented in this report. They recommend greater regulation of the private insurance industry, and more careful design of cost sharing. Even though they (inadvertently?) presented a very compelling case for eliminating private insurance and cost sharing, being from the London School of Economics, it appears that they would try to make private funding work.

Regardless, this is an excellent primer on the flaws of financing health care through private insurance and cost sharing. It is well worth downloading and retaining as an important resource in our national dialogue on reform.

Just ignore their policy recommendations and substitute ours: Let’s design our national health insurance program so that it provides comprehensive benefits for everyone, funded equitably, while removing financial barriers to care. Let’s contain costs through patent-friendly supply side mechanisms. Then we could send the private insurers on their way, and they can take their perversities with them.