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Health insurance for the 21st Century

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Health insurance for the 21st Century

Upgrading To National Health Insurance (Medicare 2.0)

The Case For Eliminating Private Health Insurance

by Leonard Rodberg & Don McCanne
CommonDreams.org
July 13, 2007

Private health insurance was an idea that worked during part of the last century; it will not succeed through the 21st Century. With jobs increasingly service-based and short-term, the large employment-based risk pools that made this insurance system possible no longer exist. Medical care has become more effective and more essential to the ordinary person, but also more costly and capital-intensive. The multiple private insurance carriers that emerged during the last century can no longer provide a sound basis for financing our modern health care system.

Alone among the nations of the world, the U.S. has relied upon private insurance to cover the majority of its population. In the mid-20th Century, when medical care accounted for barely 1% of our gross national product, medical technology was limited, and jobs lasted for a lifetime, health care could be financed through such employment-based, premium-financed health insurance. But the time for private insurance has passed.

Health care has now become a major part of our national expenditures. The premium for an individual now averages more than $4,000 per year, while a good family policy averages more than $10,000 per year, comparable to the minimum wage and nearly one-fourth of the median family income. As a consequence, though the US spends far more on health care than any other nation, we leave millions of our people without any coverage at all. And those who do have coverage increasingly find that their plans are inadequate, exposing them to financial hardship and even bankruptcy when illness strikes.

If we believe that everyone should have health care coverage, and that financial barriers should not prevent us from accessing health care when we need it, then it has become clear that the private health insurance system cannot meet our needs. Health care has simply become too expensive to be financed through private insurance premiums.

Supporters of insurance companies claim that they create efficiency through competition. However, the truth is that insurance industry is increasingly concentrated, with three national firms, United Health, Wellpoint, and Aetna, dominating the industry. And the high and rising cost of health care shows that whatever competition there was in the past has not worked to hold down costs.

Supporters of private insurance also claim that it expands consumer choice. However, the choice of plans that these companies offer is not what consumers want; it is the choice of their physician and hospital, exactly the choice that private insurance plans, in the guise of managed care, increasingly deny us.

What has been the response of the health insurance industry to this situation? To protect their markets and try to make premiums affordable, they have reduced the protection afforded by insurance by shifting more of the cost to patients, especially through high-deductible plans. They have also targeted their marketing more narrowly to the healthy portion of the population, so as to avoid covering individuals with known needs for health care. Yet premiums continue to rise each year, increasing by nearly 70% above inflation in just the last six years.

The so-called “universal health care” proposals being put forward by mainstream politicians would simply expand the current system without addressing any of its problems. They would simply mandate that either our employers provide us with coverage or we, as individuals, purchase our own coverage in the private insurance market. These plans cannot work in the face of the high cost of premium-based coverage for even the average person. (Some proposals would offer the option of buying a competing public plan, under the theory that the public program would be more efficient and effective. The flaw here is that the public plan would attract those who are unable to afford private coverage or who are paying high premiums or have no insurance because of pre-existing conditions. Placing these high-cost individuals in a separate government pool would make it unaffordable for most other people. This “death spiral” would cause the public plan to fail.)

The main impetus for renewed interest in health care reform has been the rapid rise in costs over the last few years. Yet, while most of these proposals give lip service to the need to control costs, none actually addresses the problem in a serious way. (The introduction of health information technology and “disease management”, which some of them urge, are mere placebos; they may make politicians feel better, but studies have shown they will do little to reduce costs and may actually increase them.)

Everyone acknowledges that coverage for low-income individuals must be subsidized. But what about the average-income individual and family? If they must now be subsidized as well, we might as well throw in the towel and recognize that a more efficient, more equitable financing system has to be adopted if it has any chance of providing coverage while being affordable to the society. An individual mandate to purchase private insurance cannot provide good coverage while remaining affordable, while employer-provided coverage also can no longer be sustained as the premium costs to the employer become increasingly unaffordable.

The private insurance industry spends about 20 percent of its revenue on administration, marketing, and profits. Further, this industry imposes on physicians and hospitals an administrative burden in billing and insurance-related functions that consumes another 12 percent of insurance premiums. Thus, about one-third of private insurance premiums are absorbed in administrative services that could be drastically reduced if we were to finance health care through a single non-profit or public fund. Indeed, studies have shown that replacing the multiplicity of public and private payers with a single national health insurance program would eliminate $350 billion in wasteful expenditures, enough to pay for the care that the uninsured and the underinsured are not currently receiving.

Such a single payer plan would make possible a set of mechanisms, including public budgeting and investment planning, that would allow us to address the real sources of cost increases and allow us to rationalize our health care investments. The drivers of high cost such as administrative waste, deterioration of our primary care infrastructure, excessive prices, and use of non-beneficial or detrimental high-tech services and products could all be addressed within such a rationalized system.

In sum, we will not be able to control health care costs until we reform our method of financing health care. We simply have to give up the fantasy that the private insurance industry can provide us with comprehensive coverage when this requires premiums that average-income individuals cannot afford. Instead, the U.S. already has a successful program that covers more than forty million people, gives free choice of doctors and hospitals, and has only three percent administrative expense. It is Medicare, and an expanded and improved Medicare for All (Medicare 2.0) program would cover everyone comprehensively within our current expenditures and eliminate the need for private insurance. This is the direction we must go.

Leonard Rodberg is Research Director of the New York Metro Chapter, and Don McCanne, Senior Policy Fellow, of Physicians for a National Health Program. www.pnhp.org

Upgrading To National Health Insurance (Medicare 2.0)

The Case For Eliminating Obsolete Private Health Insurance

by Leonard Rodberg & Don McCanne

Private health insurance was an idea that worked during part of the last century; it will not succeed through the 21st Century. With jobs increasingly service-based and short-term, the large employment-based risk pools that made this insurance system possible no longer exist. Medical care has become more effective and more essential to the ordinary person, but also more costly and capital-intensive. The multiple private insurance carriers that emerged during the last century can no longer provide a sound basis for financing our modern health care system.

Alone among the nations of the world, the U.S. has relied upon private insurance to cover the majority of its population. In the mid-20th Century, when medical care accounted for barely 1% of our gross national product, medical technology was limited, and jobs lasted for a lifetime, health care could be financed through such employment-based, premium-financed health insurance. But the time for private insurance has passed.

Health care has now become a major part of our national expenditures. The premium for an individual now averages more than $4,000 per year, while a good family policy averages more than $10,000 per year, comparable to the minimum wage and nearly one-fourth of the median family income. As a consequence, though the US spends far more on health care than any other nation, we leave millions of our people without any coverage at all. And those who do have coverage increasingly find that their plans are inadequate, exposing them to financial hardship and even bankruptcy when illness strikes.

If we believe that everyone should have health care coverage, and that financial barriers should not prevent us from accessing health care when we need it, then it has become clear that the private health insurance system cannot meet our needs. Health care has simply become too expensive to be financed through private insurance premiums.

Supporters of insurance companies claim that they create efficiency through competition. However, the truth is that insurance industry is increasingly concentrated, with three national firms, United Health, Wellpoint, and Aetna, dominating the industry. And the high and rising cost of health care shows that whatever competition there was in the past has not worked to hold down costs.

Supporters of private insurance also claim that it expands consumer choice. However, the choice of plans that these companies offer is not what consumers want; it is the choice of their physician and hospital, exactly the choice that private insurance plans, in the guise of managed care, increasingly deny us.

What has been the response of the health insurance industry to this situation? To protect their markets and try to make premiums affordable, they have reduced the protection afforded by insurance by shifting more of the cost to patients, especially through high-deductible plans. They have also targeted their marketing more narrowly to the healthy portion of the population, so as to avoid covering individuals with known needs for health care. Yet premiums continue to rise each year, increasing by nearly 70% above inflation in just the last six years.

The so-called “universal health care” proposals being put forward by mainstream politicians would simply expand the current system without addressing any of its problems. They would simply mandate that either our employers provide us with coverage or we, as individuals, purchase our own coverage in the private insurance market. These plans cannot work in the face of the high cost of premium-based coverage for even the average person. (Some proposals would offer the option of buying a competing public plan, under the theory that the public program would be more efficient and effective. The flaw here is that the public plan would attract those who are unable to afford private coverage or who are paying high premiums or have no insurance because of pre-existing conditions. Placing these high-cost individuals in a separate government pool would make it unaffordable for most other people. This “death spiral” would cause the public plan to fail.)

The main impetus for renewed interest in health care reform has been the rapid rise in costs over the last few years. Yet, while most of these proposals give lip service to the need to control costs, none actually addresses the problem in a serious way. (The introduction of health information technology and “disease management”, which some of them urge, are mere placebos; they may make politicians feel better, but studies have shown they will do little to reduce costs and may actually increase them.)

Everyone acknowledges that coverage for low-income individuals must be subsidized. But what about the average-income individual and family? If they must now be subsidized as well, we might as well throw in the towel and recognize that a more efficient, more equitable financing system has to be adopted if it has any chance of providing coverage while being affordable to the society. An individual mandate to purchase private insurance cannot provide good coverage while remaining affordable, while employer-provided coverage also can no longer be sustained as the premium costs to the employer become increasingly unaffordable.

The private insurance industry spends about 20 percent of its revenue on administration, marketing, and profits. Further, this industry imposes on physicians and hospitals an administrative burden in billing and insurance-related functions that consumes another 12 percent of insurance premiums. Thus, about one-third of private insurance premiums are absorbed in administrative services that could be drastically reduced if we were to finance health care through a single non-profit or public fund. Indeed, studies have shown that replacing the multiplicity of public and private payers with a single national health insurance program would eliminate $350 billion in wasteful expenditures, enough to pay for the care that the uninsured and the underinsured are not currently receiving.

Such a single payer plan would make possible a set of mechanisms, including public budgeting and investment planning, that would allow us to address the real sources of cost increases and allow us to rationalize our health care investments. The drivers of high cost such as administrative waste, deterioration of our primary care infrastructure, excessive prices, and use of non-beneficial or detrimental high-tech services and products could all be addressed within such a rationalized system.

In sum, we will not be able to control health care costs until we reform our method of financing health care. We simply have to give up the fantasy that the private insurance industry can provide us with comprehensive coverage when this requires premiums that average-income individuals cannot afford. Instead, the U.S. already has a successful program that covers more than forty million people, gives free choice of doctors and hospitals, and has only three percent administrative expense. It is Medicare, and an expanded and improved Medicare for All (Medicare 2.0) program would cover everyone comprehensively within our current expenditures and eliminate the need for private insurance. This is the direction we must go.

Leonard Rodberg is Research Director of the New York Metro Chapter, and Don McCanne, Senior Policy Fellow, of Physicians for a National Health Program. www.pnhp.org

Linking campaign financing to what's wrong with the health care system

Shifting to public funding of campaigns could be a big first step toward health care coverage for everyone.

By Jack E. Lohman
COMMENTARY | July 16, 2007
jlohman@execpc.com

Health care is looming as a major issue in the 2008 elections, but a root cause of soaring health care costs is being ignored both by the public and the press, at least until now. I’m referring to a very conflicted system of political campaign financing.

Think about it. Had the insurance industry not been a major contributor, we’d have fixed our health care system years ago. Its biggest single problem is the huge portion of total health care costs — about 31 percent, according to a group called Physicians for a National Health Program and others — that are consumed by the insurance and billing bureaucracy without ever providing direct patient care. Costs for marketing, broker sales commissions, actuarial costs, gatekeepers, high executive salaries, increasing shareholder profits, even the high costs of their lobbying and campaign contributions are passed on to the patient (and in most cases employers, who have been taking their jobs offshore to avoid the costs).

Eliminate that waste and we could expand health care coverage to 100 percent of our people for the same dollars we spend to cover just 85 percent today.

But that means eliminating the very profitable yet wasteful insurance component, and the insurance industry will have nothing of that. So its executives are sending big cash dollars to the very state and federal politicians that can block or approve progress. They are bribing my representatives and yours to guard their own profits.

The media must not allow this process to go unchecked. When there is a political fight, it’s usually because money is involved on one side or the other. And when it affects the public, that side generally has a lot of citizen volunteers with little cash fighting a goliath industry with lots of cash going to the politicians that pass the laws. The public’s only equalizer is the press, and it too often ignores the driving force: money.

Politicians get offended when they hear charges of corruption. They seem to think they can continue representing “us” while receiving money from “them.” Robert Kennedy, Jr., calls it political treason, and he’s not far off base.

As a former CEO, had I allowed my employees to accept money from vendors while giving away company assets, my company would have crashed and my employees put out of jobs. So how can our state and nation survive under this same kind of corruption?

It can’t, and it is only a matter of time before Americans begin migrating to other countries to escape it. We are in a slow-motion spiral downward. Jobs are being outsourced daily and Americans will eventually follow them. We cannot survive as a consumer-only nation.

Health care is just one of many issues that are robbing our population of its resources. Whatever your issue — energy, environment, high taxes or whatever — follow the money and you’ll find politicians at the other end with their hands out, all while claiming a purity we could only hope for.

The only reasonable solution is to have the electoral system financed by the people the politicians should be beholden to, the taxpayers. Private interests are currently funding our public electoral system, the last place you would expect privatization and the free market to exist.

Full public funding of political campaigns, like the system promoted by Public Campaign and Wisconsin Clean Elections Coalition, would cost $10 per taxpayer per year at the federal level and would eliminate the $300 billion per year the Feds give away to the special interests that currently fund the elections. Subsidies, tax breaks, no bid contracts and local pork are all on the long list of government handouts. If we paid a hundred times the $10 per taxpayer, it would be a bargain.

For the system to be constitutional it must be optional, thus politicians can opt in or opt out of the public system. Those opting in would receive a sufficient amount of money to run a credible campaign. Those opting for private cash should be allowed to prostitute themselves to the fullest extent possible; but with full disclosure of their money source.

Then let the voters decide whom they want representing them. In the states that have adopted this system, Arizona and Maine, the voters have selected the public candidate for over 65 percent of their elected seats.

The Democrats have promised reform, but it apparently is not high on their list. They must now deliver. And if they don’t it is up to the voters to oust those in 2008 who fail to fix the system. And that includes the candidates in both parties who oppose reform. We must give our democracy back to the people.

Jack Lohman, a free-lance writer, is a retired business owner in Wisconsin with 35 years in the health care industry.

The Waiting Game

By PAUL KRUGMAN
New York Times
Published: July 16, 2007

Being without health insurance is no big deal. Just ask President Bush. “I mean, people have access to health care in America,” he said last week. “After all, you just go to an emergency room.”
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This is what you might call callousness with consequences. The White House has announced that Mr. Bush will veto a bipartisan plan that would extend health insurance, and with it such essentials as regular checkups and preventive medical care, to an estimated 4.1 million currently uninsured children. After all, it’s not as if those kids really need insurance — they can just go to emergency rooms, right?

O.K., it’s not news that Mr. Bush has no empathy for people less fortunate than himself. But his willful ignorance here is part of a larger picture: by and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada.

The claim that the uninsured can get all the care they need in emergency rooms is just the beginning. Beyond that is the myth that Americans who are lucky enough to have insurance never face long waits for medical care.

Actually, the persistence of that myth puzzles me. I can understand how people like Mr. Bush or Fred Thompson, who declared recently that “the poorest Americans are getting far better service” than Canadians or the British, can wave away the desperation of uninsured Americans, who are often poor and voiceless. But how can they get away with pretending that insured Americans always get prompt care, when most of us can testify otherwise?

A recent article in Business Week put it bluntly: “In reality, both data and anecdotes show that the American people are already waiting as long or longer than patients living with universal health-care systems.”

A cross-national survey conducted by the Commonwealth Fund found that America ranks near the bottom among advanced countries in terms of how hard it is to get medical attention on short notice (although Canada was slightly worse), and that America is the worst place in the advanced world if you need care after hours or on a weekend.

We look better when it comes to seeing a specialist or receiving elective surgery. But Germany outperforms us even on those measures — and I suspect that France, which wasn’t included in the study, matches Germany’s performance.

Besides, not all medical delays are created equal. In Canada and Britain, delays are caused by doctors trying to devote limited medical resources to the most urgent cases. In the United States, they’re often caused by insurance companies trying to save money.

This can lead to ordeals like the one recently described by Mark Kleiman, a professor at U.C.L.A., who nearly died of cancer because his insurer kept delaying approval for a necessary biopsy. “It was only later,” writes Mr. Kleiman on his blog, “that I discovered why the insurance company was stalling; I had an option, which I didn’t know I had, to avoid all the approvals by going to ‘Tier II,’ which would have meant higher co-payments.”

He adds, “I don’t know how many people my insurance company waited to death that year, but I’m certain the number wasn’t zero.”

To be fair, Mr. Kleiman is only surmising that his insurance company risked his life in an attempt to get him to pay more of his treatment costs. But there’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their “medical losses” — the industry term for actually having to pay for care.

On the other hand, it’s true that Americans get hip replacements faster than Canadians. But there’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.

The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.

Rationing under U.S. Medicare and Canadian Medicare

The Waiting Game

By Paul Krugman
The New York Times
July 16, 2007

…it’s true that Americans get hip replacements faster than Canadians. But thereĆ¢ā‚¬ā„¢s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that’s what they call their system) because it has more lavish funding — end of story. The alleged virtues of private insurance have nothing to do with it.

http://select.nytimes.com/2007/07/16/opinion/16krugman.html

Comment:

By Don McCanne, MD

Paul Krugman’s comments apply not only to hip replacement, but also to other queue problems reported in Canada, such as cataract surgery, cancer therapy, and non-urgent cardiac surgery. In the United States, these services are provided predominantly under Medicare, our public insurance program.

Excessive queues are eliminated by making minor, selective adjustments in the capacity of the system, and by simple queue management techniques. Compared to the global costs of establishing and maintaining a health care system, the costs of these adjustments are negligible.

Responsible stewards of any health care system, whether public or private, will make these appropriate adjustments. The difference is that the public system would be adapted to accommodate everyone, whereas private systems accommodate only those with the ability to pay.

All systems ration care. Excessive rationing due to limited capacity is very easily remedied, as has been demonstrated in many nations with publicly-financed health care systems. Rationing by ability to pay, in contrast, results in suffering and death.

It’s time for the United States to include everyone in our health care system. We can deal with the queue problem by monitoring the system and making minor adjustments as appropriate. That shouldn’t require any more effort than we already expend on monitoring financial hardship and impaired health outcomes, including death, due to our highly flawed system of financing health care.

Grieve for the U.S. health system

BY MARTIN GROSS
Miami Herald
Sun, Jul. 08, 2007

It isn’t surprising that critics of Michael Moore’s Sicko are desperate to quibble with his finer points. After all, denial is the first stage of Elizabeth Kübler-Ross’s model of dealing with grief, and the tragedy before us is, of course, the agonizing death of an inadequate medical system.

Denial is normal when faced with the sad state of American healthcare. Who wants to hear that roughly one in six of us are uninsured and can’t get access to care? Who cares that we have the 37th-best medical system in the world? Who needs to know that 18,000 American citizens may be dying each year because this country’s system is not comprehensive or universal? This data came from the World Health Organization and the Institute of Medicine? Well, who are they to judge?

Anger is the next logical step. Come on, this is American healthcare! This country’s got moon men, purple mountains’ majesty and a per-capita healthcare expenditure that’s twice as much as that of any other industrialized nation. It should make our blood boil that we don’t nearly get what we pay for. And yet we all have a story about a family member, friend or ourselves that relates to the substandard treatment patients receive in this country — stories that range from the exasperating to the infuriating.

It may seem sensible to bargain with private insurers when confronting our fate at their hands. Massachusetts is grappling with a plan to mandate private (and some public) health insurance coverage for all citizens. Those who can afford to are pumping money into the coffers of health insurers, while the state takes up the slack for the rest. But flooding the private insurance market with public money is a feeble solution. And wouldn’t it make more sense to transfer this largess to actual medical care, thus eliminating the inefficient profit-taking middleman?

I came to medical school with the idea of improving the healthcare system for the sake of my future patients and my future career. But so far, all I’ve learned at school is that struggling daily against health insurers and HMOs leads to a deep depression on the part of health practitioners. I’ve spoken to dozens of doctors about my future. They are accomplished people; many are role models, a few are my heroes. Yet every single one has tried to discourage me from entering the profession. The business side has overwhelmed the art of medicine.

Again, echoing Kübler-Ross, all that remains is to accept our fate. Or, we can accept the best solution available, a universal single-payer system that eliminates private insurers and provides cradle-to-grave coverage for all.

So when you hear arguments and proposals that deny the facts, that take issue with what Michael Moore is documenting, that urge us to bargain with private insurers — and in general, ask us to wallow in self-pity — be prepared to accept the worst.

Or you can get out there and fight for your life with the rest of us.

The writer is a second-year student at New Jersey Medical School and a co-president of the local student chapter of Physicians for a National Health Program — PNHP.org — an organization that advocates for single-payer universal healthcare in the United States. He is the son of Liza Gross, The Miami Herald’s managing editor/presentation.

'SiCKO' Exposes Broken System

By Susanne L. King
Berkshire Eagle
Friday, July 13

A MAN sews up the gaping wound in his own leg because he has no health insurance. Another decides whether to save his ring finger for $12,000, or his middle finger for $60,000, since he can’t afford reconstructive surgery for both fingers.

So begins “Sicko,” Michael Moore’s new documentary on the failures and travesties of the United States’ health care system, which leaves almost 50 million people uninsured and many more underinsured.

These stories are only two of the 25,000 that Moore received when he sent an e-mail request for reports from patients who have experienced difficulties with the health care system. With these stories of shattered lives, Moore masterfully weaves a powerful narrative that is an indictment of our health care system. He shows us people who suffer unnecessary pain, chaos, indignity and death because of their lack of access to health care.

Moore details the failures of our system by focusing on working adults who can’t get insurance because of pre-existing conditions, who have insurance but can’t afford their co-payments and deductibles, or who have been denied coverage by their insurance companies when they develop a health problem.

The people around me cried as we watched a middle-aged couple move into a small room in their daughter’s house after declaring medical bankruptcy. The husband had survived three heart attacks and his wife had developed cancer. Even though both had been gainfully employed and had insurance, they went bankrupt in their retirement years because of “cost-sharing,” the term insurance companies use for sticking patients with high deductibles and co-payments.

By showing how having insurance does not guarantee access to health care in America, Moore highlights the underhanded practices of insurance companies. A devastated mother describes her child’s death, which occurred because the family’s managed care insurance company would not pay for treatment at the closest hospital emergency department.

A former medical reviewer, Dr. Linda Peeno, cries as she testifies in a government hearing about the practices she implemented to deny care to patients insured by Humana before she quit her job in protest. .

Moore not only details the problems of our current health care system, he also shows us the solution. He supports a national health care plan, similar to that of every other industrialized country in the world. He goes to Canada, Great Britain, France, and, yes, to Cuba, to highlight the benefits of a single-payer plan funded and administered by the government.

He also debunks the myths and distortions about a national health plan, which are promulgated by the insurance companies, including the specter of “waiting lines,” and the bogeyman of “socialized medicine.” As he points out, we have “socialized” education, “socialized” police and fire departments, and a “socialized” postal service.

The truth is that a national health plan would not be “socialized medicine,” as doctors and hospitals that are now private would remain so. The change would be in the administration of the health care funds. Rather than a system with multiple insurance companies that drains health care coffers of 31 percent of the health care dollars, the government would be the “single payer” and administer the funds. (The administrative costs for Medicare are 3.6 percent, and Canadian costs are 1.3 percent). A similar system in the United States would save $300 billion annually.

In addition, patients would be able to choose their own doctors and hospitals, without intrusion into their health care decisions by faceless bureaucrats.

Moore raises the moral issue of denying patients access to health care in our country. A wonderful moment in the film occurs when he talks with a conservative party member in Canada who strongly supports his national health care system. The Canadian conservative believes that society should support equal access to health care for each person, regardless of means, even though that might affect his own pocketbook. This is not a partisan movie: This documentary is about social values and the right of everyone to have adequate and affordable health care.

While there is humor in this movie, the stories elicit raw emotions of sadness and rage. Unlike his previous movies, Moore is not confrontational; he just lets people tell their gripping stories. “Sicko” will help you better understand the problems of our health care system, and it makes a strong case for a national health plan as the obvious solution.

See this movie, and then call your legislators and ask them to sponsor the current national health care legislation in Congress, H. R. 676.

Prescription for reform

PERSON OF INTEREST: DR ARNOLD RELMAN

By Judith Graham
Tribune staff reporter
Published July 1, 2007

In 1980, Dr. Arnold Relman penned a famous article in the New England Journal of Medicine warning of the rise of a new, powerful “medical-industrial complex” in the U.S. The commercialization of medicine, he argued, was not in patients’ or society’s best interest and undercut the ethics of the profession. A longtime editor of the New England Journal and professor at Harvard Medical School, Relman tackles the issue again in his new book, “A Second Opinion,” published by PublicAffairs. This time he calls for a complete overhaul of the way medical care is delivered and paid for. Last week, Relman presented the case for radical reform of health care at the Union League Club in Chicago. Before that he spoke with the Tribune. An edited transcript follows.

Q. Many experts say the biggest problem in health care today is 46 million Americans with no health insurance. You say costs are the biggest problem in medicine today. Why?

A. When you step back and ask what’s going on, what’s the basic difficulty here, it’s that our health-care system is exorbitantly expensive. That’s the central problem. The lack of insurance coverage is secondary. If we get a grip on costs, we can afford to extend coverage.

Q. Why are costs so out of control?

A. It’s a complicated picture. Some causes are common to all modern health systems. People are living longer everywhere and chronic diseases connected with old age are becoming more common. Heart disease. Diabetes. Arthritis. These are expensive conditions to treat. Also, medicine has become very sophisticated and high-tech. The tests and procedures doctors order up are very elaborate and costly. What makes medicine in the U.S. more expensive than in all the other countries is the commercialization of our health-care system. Health care has become a big business over the last 30 years. It doesn’t matter if you’re for-profit or not-for-profit, every one is concerned about maximizing income. That includes a lot of doctors.

Q. What’s wrong with that?

A. There’s a basic conflict of interest. The assumption has always been when you to go the doctor he or she has a professional responsibility to put your needs above everything else. That’s changed. Now, when a doctor has a significant financial interest in a facility or in a piece of equipment, the doctor is torn between his or her own economic interests and the patient’s needs. … The patient can no longer be sure whose side the doctor is on.

Q. In your book, you say you’re convinced that the private marketplace won’t succeed in controlling costs or safeguarding quality. Why?

A The health-care market has failed, and if we continue to rely on the market the failure will only deepen. A very smart economist, Kenneth Arrow, a professor at Stanford, explained in the American Economic Review in 1963 that health care isn’t like any other market. The people who purchase medical care, patients, aren’t in the position to pick or chose what they want or need. When you’re sick and worried, you don’t know what’s wrong with you. And you’re not going to find it on the Web. It’s not like buying anything else. Then, you have the fact that doctors run the system. It’s not patient-driven. It’s not consumer-driven. It’s doctor-driven. And the doctors, for the most part, are paid on a piecework basis. Fee for service. You get paid for what you do. If there ever was a system that’s going to drive up costs, it’s a system like we have. Because the more doctors do, the more procedures, the more tests, the more money they get paid.

Q. What needs to be changed, then?

A. The fee-for-service system has to go. It won’t work anymore. … The vast bulk of medical service should be delivered by doctors paid a salary for their time and effort. That would bring medicine in line with most other lawyers and architects and engineers and accountants and teachers. And you need an integrated, organized system of doctors who manage their own affairs. The model should be prepaid group practices, like the Mayo Clinic and the Marshfield Clinic in Wisconsin and the Kaiser Permanente medical groups and many others.

Q. You suggest the entire delivery of health care has to be overhauled. Why?

A. Because medicine has become fractionated, divided up into multiple specialties that don’t communicate with each other and that duplicate each other’s efforts. It’s a jungle out there for a patient trying to find his or her way through the system. … In multispecialty practice, doctors work together as a team and share information and don’t compete with one another. … I believe We need a single-payer system of health care that covers everyone, like Medicare for the elderly. But first you have to change the incentives that drive the delivery of care and how that care is organized.

Q. Do you think doctors will ever accept this?

A. They will. … You know why? The practice of medicine is getting to be more and more stressful, and doctors are less and less satisfied. They’re beginning to realize, it can’t go on this way. … Ultimately, if the system doesn’t change in the fundamental way I’m predicting, what’s going to happen is the practice of medicine will be run by corporations or it’ll become socialized and doctors will work for the government.

jegraham@tribune.com

Copyright (c) 2007, Chicago Tribune

SEIU United Healthcare Workers West "Strongly" Supports HR 676

Oakland, California. The 140,000 member United Healthcare Workers West, an affiliate of SEIU, has endorsed HR 676, legislation introduced by Congressman John Conyers (D-MI) which would implement a single payer healthcare system in the U.S.

In a letter to Conyers’ office announcing the endorsement, Richard Thomason, Policy Director for the union, expressed the union’s “strong support for HR 676” and went on to state:

“Like every other industrialized nation, the United States should provide health security for its residents as a matter of basic human dignity. Your legislation would accomplish that critically important goal.

“Our local represents 140,000 caregivers who work in hospitals, clinics, nursing homes and homecare programs across California. Every day our member see the harmful consequences of being uninsured among their family members and the people they care for on the job. HR 676 will ensure that all Americans have health coverage through a publicly financed, privately delivered health care system that provides high quality, cost- effective health care.”

United Healthcare Workers West is the second largest local in the SEIU. The largest, 1199SEIU United Healthcare Workers East has also endorsed HR 676 along with Local 73 in Chicago and Pennsylvania locals 668 and 1199P.

‘SiCKO’ Exposes Broken System

By Susanne L. King
Berkshire Eagle
Friday, July 13

A MAN sews up the gaping wound in his own leg because he has no health insurance. Another decides whether to save his ring finger for $12,000, or his middle finger for $60,000, since he can’t afford reconstructive surgery for both fingers.

So begins “Sicko,” Michael Moore’s new documentary on the failures and travesties of the United States’ health care system, which leaves almost 50 million people uninsured and many more underinsured.

These stories are only two of the 25,000 that Moore received when he sent an e-mail request for reports from patients who have experienced difficulties with the health care system. With these stories of shattered lives, Moore masterfully weaves a powerful narrative that is an indictment of our health care system. He shows us people who suffer unnecessary pain, chaos, indignity and death because of their lack of access to health care.

Moore details the failures of our system by focusing on working adults who can’t get insurance because of pre-existing conditions, who have insurance but can’t afford their co-payments and deductibles, or who have been denied coverage by their insurance companies when they develop a health problem.

The people around me cried as we watched a middle-aged couple move into a small room in their daughter’s house after declaring medical bankruptcy. The husband had survived three heart attacks and his wife had developed cancer. Even though both had been gainfully employed and had insurance, they went bankrupt in their retirement years because of “cost-sharing,” the term insurance companies use for sticking patients with high deductibles and co-payments.

By showing how having insurance does not guarantee access to health care in America, Moore highlights the underhanded practices of insurance companies. A devastated mother describes her child’s death, which occurred because the family’s managed care insurance company would not pay for treatment at the closest hospital emergency department.

A former medical reviewer, Dr. Linda Peeno, cries as she testifies in a government hearing about the practices she implemented to deny care to patients insured by Humana before she quit her job in protest. .

Moore not only details the problems of our current health care system, he also shows us the solution. He supports a national health care plan, similar to that of every other industrialized country in the world. He goes to Canada, Great Britain, France, and, yes, to Cuba, to highlight the benefits of a single-payer plan funded and administered by the government.

He also debunks the myths and distortions about a national health plan, which are promulgated by the insurance companies, including the specter of “waiting lines,” and the bogeyman of “socialized medicine.” As he points out, we have “socialized” education, “socialized” police and fire departments, and a “socialized” postal service.

The truth is that a national health plan would not be “socialized medicine,” as doctors and hospitals that are now private would remain so. The change would be in the administration of the health care funds. Rather than a system with multiple insurance companies that drains health care coffers of 31 percent of the health care dollars, the government would be the “single payer” and administer the funds. (The administrative costs for Medicare are 3.6 percent, and Canadian costs are 1.3 percent). A similar system in the United States would save $300 billion annually.

In addition, patients would be able to choose their own doctors and hospitals, without intrusion into their health care decisions by faceless bureaucrats.

Moore raises the moral issue of denying patients access to health care in our country. A wonderful moment in the film occurs when he talks with a conservative party member in Canada who strongly supports his national health care system. The Canadian conservative believes that society should support equal access to health care for each person, regardless of means, even though that might affect his own pocketbook. This is not a partisan movie: This documentary is about social values and the right of everyone to have adequate and affordable health care.

While there is humor in this movie, the stories elicit raw emotions of sadness and rage. Unlike his previous movies, Moore is not confrontational; he just lets people tell their gripping stories. “Sicko” will help you better understand the problems of our health care system, and it makes a strong case for a national health plan as the obvious solution.

See this movie, and then call your legislators and ask them to sponsor the current national health care legislation in Congress, H. R. 676.

SEIU United Healthcare Workers West “Strongly” Supports HR 676

Oakland, California. The 140,000 member United Healthcare Workers West, an affiliate of SEIU, has endorsed HR 676, legislation introduced by Congressman John Conyers (D-MI) which would implement a single payer healthcare system in the U.S.

In a letter to Conyers’ office announcing the endorsement, Richard Thomason, Policy Director for the union, expressed the union’s “strong support for HR 676” and went on to state:

“Like every other industrialized nation, the United States should provide health security for its residents as a matter of basic human dignity. Your legislation would accomplish that critically important goal.

“Our local represents 140,000 caregivers who work in hospitals, clinics, nursing homes and homecare programs across California. Every day our member see the harmful consequences of being uninsured among their family members and the people they care for on the job. HR 676 will ensure that all Americans have health coverage through a publicly financed, privately delivered health care system that provides high quality, cost- effective health care.”

United Healthcare Workers West is the second largest local in the SEIU. The largest, 1199SEIU United Healthcare Workers East has also endorsed HR 676 along with Local 73 in Chicago and Pennsylvania locals 668 and 1199P.

I Treat the Patients Michael Moore Forgot

By Thomas L. Fisher
Washington Post
Sunday, July 1, 2007; Page B02

CHICAGO At 4 a.m., the ambulance rushed the driver in a single-car accident to the emergency room where I was the attending physician. The victim, a man in his late 20s, had been knocked unconscious when his head slammed into the windshield. The paramedics handed me two-thirds of his scalp in a plastic bag.

That sounds horrible, of course, but modern medicine can do a lot in such cases — if it has the chance. Our team worked to stabilize the patient and to save his scalp. Human tissue can die in a just few hours if it’s cut off from its blood supply. So to avoid a disfiguring injury, our patient would need the care of a specialist who could reattach his scalp’s blood vessels. Unfortunately, my hospital didn’t have such a surgeon; the closest one worked at a sibling hospital in a more affluent neighborhood 15 miles away.

We raced against time to avoid permanent tissue damage. I called and called and called, searching for a physician willing to take care of our patient. But no one would accept him. After 40 minutes, we flew him — and his dying scalp — by helicopter to a hospital 45 minutes away.

The patient should have been recuperating after a close call. Instead, by the time he was whisked away from me, he was facing lifelong disfigurement. This is the reality I see every day as an ER doctor: Large groups of people — mainly those from communities of color, and also those who are poor and uninsured — are not receiving basic care that can make all the difference.

Many Americans have been talking more about health care these days because of the buzz around Michael Moore’s new documentary, “Sicko,” a polemical look at unfairness in the nation’s health care industry. However, the types of communities I care for are barely addressed. Moore says up front in the movie that he is not focusing on the nearly 50 million people who have no access to care at all. His decision to concentrate instead on the substandard care given to the working and insured is an understandable attempt to touch the heartstrings of Middle America. Unfortunately, by giving cursory treatment to race and class, he avoided tackling the most intractable problems in this country’s health care system.

Here’s the view from the front lines: Hospital waiting times of 10, 12 hours. Emergency rooms so packed that ambulances must be turned away. People suffering from ailments ranging from organ failure to psychotic breakdowns, all preventable.

These issues affect not only individuals, but whole communities and the health outlets serving them. I sympathize with those who are unhappy about the quality of their insured care, but I’m more worried about those with no insurance at all. The bigger problem is that we all want the finest of health care, and as a result, many of us — largely black and brown — are left with nothing.

One scene in “Sicko” does deal directly with race: A white woman questions whether her husband, who is black and has kidney cancer, would receive better care if he were white. I can’t speak to their situation, but my experience is that the influence of race and racism on health care is rarely that obvious. But it is unmistakable, nonetheless.

For instance, the young driver in the car accident essentially had the misfortune of getting hurt in the wrong part of town. At the time, I was an emergency medicine physician fresh out of residency, working in a community hospital system in the Midwest that consisted of two very different hospitals. Hospital A (where the patient started) served a blighted, post-industrial city of about 100,000 residents, about 85 percent of whom are black and largely poor and uninsured. Hospital B (the one we couldn’t get him into) is 15 miles away, in a more affluent community of about 30,000 people, about 70 percent of whom are white. Although technically the two comprised a single hospital system, physicians were allowed to choose to work at one or both of the locations. Most chose Hospital B, leaving few specialists on call for emergencies at Hospital A. By dumb luck, my patient wound up at the wrong hospital, and that made all the difference.

The reasons behind the two-tier structure weren’t malicious. In most hospital systems, physicians are not direct employees but instead have privileges to deliver care through the facility. In this structure, the patient receives one charge from the doctor and one from the hospital. That means there’s less of a financial incentive to work in communities with many uninsured members. Many specialists did not want to leave their neighborhoods and their families in the middle of the night and disrupt their upcoming workday schedule to care for a patient who may not be able to pay but could nevertheless file suit over care.

It’s honest to say that most poor people — not just those from communities of color — suffer from inadequate or nonexistent care. But I’ve found that decisions that seem race-neutral at face value can systematically hurt such groups. These decisions create racial disparities in health care that go beyond what can be explained by class alone. The challenge presented by that emergency case at 4 a.m. was determined by the earlier decision not to require physicians to provide care at both hospitals. The difference in care between these two facilities went beyond just a single car-accident victim and wounded the entire community that Hospital A was supposed to serve.

These are the kinds of systemic problems that lead to widespread racial disparities in health. Consider the medical picture for my black male peers. According to the Henry J. Kaiser Family Foundation, black men are the least healthy ethnic group in the United States. Their death rate (1,282 per 100,000 in 2004) outstrips that of all other ethnic groups, including non-Hispanic whites, 949; Native Americans, 750.2; Hispanics, 702.7; and Asians, 534.1. Black men also have higher rates of heart disease, HIV/AIDS and certain kinds of cancer, including prostate, lung and colon.

Such statistics send a larger message about medical care and race: The lack of equity seen in wealth, income, education and insurance has considerable impact on health.

On balance, the middle and upper-middle classes are relatively healthy, as evidenced by their lengthening life spans and rising quality of life. Meanwhile, the bad outcomes disproportionately affect the poor, including many working-class and poor whites but more often people of color. In these populations, health and health care in the United States are not dissimilar to the standards in some developing nations. For instance, in 2005, the average life expectancy for black men in this country was 69.2 years; according to CIA estimates for 2007, the life expectancy for all Iraqis is 69.3.

Health care is not a run-of-the-mill service like an oil change. It’s a massive industry that shapes our lives and sometimes saves them. But our health care options are more than just commodities. That being said, providing health care to the underserved alone will not solve every problem — broader issues of equity will need to be addressed.

Many Americans oppose a single-payer health care system. My support of this initiative has grown from witnessing inequities daily through years in an emergency room.

I hear the concern about such a system; people worry that they won’t get what they need, that the government will ration health care. But in fact, that’s exactly what we have right now. It’s just a little more subtle, a form of rationing that’s based on a person’s ability to endure hours of anxiety in the ER, to wait for the next medical appointment, to afford high-quality insurance.

So how can we have a public discussion about this subject? This country has limited resources to devote to health care. But it also is saddled with an inefficient health care system that gives advantages to the privileged and well-off while ignoring preventive care and abandoning those most in need.

In some ways, given escalating costs, health care is a zero-sum game. So what are people willing to give up, and what care should be provided to all? Many middle-class Americans take comfort from knowing that their health care is covered. But all those little choices add up to big society-wide choices and market incentives for drug companies — and produce an America where one man pops his Medicare-covered Viagra pills while another can’t get life-saving cancer medication.

Many Americans do get the Mercedes-Benz of health care. But given the scarcity of resources, they may be doing so at the expense of many others. Ultimately, we will need to find a middle option — providing all Americans with the health care equivalent of a Prius, a vehicle that will take efficiently to where you need to go and is affordable enough that nobody will have to walk. Because you never know what neighborhood you may wind up driving in.

tfishermd@gmail.com

Thomas L. Fisher serves on the faculty of the University of Chicago’s Department of Medicine and practices in the emergency room at the University of Chicago Medical Center.