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A Health Care Disaster (Kristof)

A Health Care Disaster
By Nicholas D. Kristof

Kiln, Miss.

In the richest country in the world, a man named Eugene Johnson is going blind in a homeless shelter, because his eye medicine washed away in Hurricane Katrina and he can’t afford to buy more.

At one level, that’s an indictment of the official rescue effort: the authorities were sufficiently concerned about hurricanes that last year they pre-positioned 10,000 body bags in New Orleans, but they dozed as Katrina approached.

Yet at a deeper level, Mr. Johnson’s plight is a window into our broken health care system. Sure, we need to think about how to rebuild New Orleans, but we also need to reconstruct a sensible health care system.

And that task is urgent, for one study suggests that more than 18,000 Americans will die this year as a consequence of not having health insurance.

Barbara Bush thought that Hurricane Katrina worked out pretty well for the poor. (“Many of the people in the arena here, you know, were underprivileged anyway,” she said after touring the Astrodome, “so this is working very well for them.”) I’d like her to come here to the rural Mississippi town of Kiln, near the Louisiana line, and meet Mr. Johnson. A barrel-chested retired plumber, a white man of 57, Mr. Johnson suffers from diabetes that has already cost him two toes. Complications also threaten his eyesight, and so he must take nine prescription medicines, including two to preserve his vision.

But the hurricane destroyed Mr. Johnson’s house. Since then, he has been bouncing from one shelter to the next and is now sleeping on a cot in a school gymnasium, along with his wife and four of his five children (one is grown and has left home).

Once Mr. Johnson found a pharmacy that was open and had one of the medicines he needs. But it charged $119 for it, and he couldn’t afford that. So Mr. Johnson is slowly going blind.

“My eyes are starting to mess up,” Mr. Johnson explained. “I see little spots. And then sometimes they all move around, like a TV picture that’s gone bad.”

Finally, a first-rate aid group, Children’s Health Fund, brought doctors and a mobile clinic to Mr. Johnson’s shelter. One of the doctors, David Krol, examined Mr. Johnson, was horrified, and is working on obtaining the medications he needs. But as Dr. Krol described the mobile clinic: “We’re a stopgap. Nothing more.”

If Mr. Johnson were more mobile, more adept at working the system, and more of a complainer, he might have gotten help earlier. But the poor tend to be stuck in shelters, without vehicles, and many are busy looking after small children. And many, like Mr. Johnson, are disastrously polite, patient, deferential and even cheerful. Around here, if you have the patience of Job, you suffer like Job.

Nearly every medical worker I spoke to warned that there would be a surge in deaths from heart disease, strokes and other ailments, concentrated among the poor, because of the interruption in medicines. Dr. Jay Lemery told of treating a single mother in a shelter whose three children were bouncing off the walls because they had attention-deficit disorder and hadn’t had their medication. The mother herself was prone to depression and had run out of her own medicine as well – in an environment that would make Pangloss suicidal.

The shelter was hot and tempers were so frayed that two women were having a fistfight. Dr. Lemery added: “Even the Red Cross people, who have the patience of Mother Teresa, were in tears.”

Yet the reality is that our medical system failed this region long before Katrina arrived. One of the Children’s Health Fund doctors discovered a previously undetected hole in a 4-year-old boy’s heart. The mother said nobody had ever listened to the boy’s chest before.

In both Mississippi and Louisiana, infant mortality is worse (for every 1,000 babies born, 10 die in their first year of life) than in Costa Rica (8 die per 1,000). For black babies in either state, the picture is still more horrifying: 15 die per 1,000. In poor, war-torn Sri Lanka, where per capita medical spending is only $131, babies have better odds, with 13 dying per 1,000.

So let’s rebuild the levees, but let’s also construct a health care system that works. A dozen years after the last, failed attempt to reform health care, the system is more broken than ever. For the sake of Mr. Johnson, and for our children, it’s time to try again.

U.S. cancer expert: Canadians aren't aware of value of medicare system

Provided by: Canadian Press
Written by: JOHN COTTER
Sep. 27, 2005

EDMONTON (CP) – World-renowned cancer specialist Eduardo Bruera is homesick for Canada’s health-care system.

Dr. Bruera left Edmonton’s Cross Cancer Institute after 15 years in 1999 to become chairman of the department of palliative care at the University of Texas M.D. Anderson Cancer Center in Houston. After working in both countries, Bruera, an oncologist, has a message for people who complain about medicare or who want to expand the use of private health insurance in Canada.

“The portability and the universality of health care in Canada are unbelievably good. I think Canadians are not aware of that,” said Bruera, who was to compare care in the two countries in a speech Wednesday at the annual conference of the Canadian Hospice Palliative Care Association.

“Don’t look at the United States. The public health-care system makes it possible for patients to access palliative care in Canada earlier and more effectively.”

Since moving to Texas, Bruera said he can’t get over the spectre of crushing debt that even upper-middle-class Americans face when a family member is dying from an advanced illness.

Even premium private health insurance in the United States rarely covers all the costs, which can lead to bereaved survivors facing an almost never ending list of medical bills, he said.

Of every $100 spent by families on medical care at the M.D Anderson Centre, only $32 is paid for by private insurance, he said.

More than 41 million Americans don’t have health insurance, he said. Of those who are insured, one in three will lose all their financial assets during illness.

“To me it is an enormous impact on quality of life. The burden of dying in the U.S. of cancer is much heavier than the burden . . . in Canada.”

Bruera’s remarks come as the federal and provincial governments work to come to grips with a Supreme Court of Canada decision in a Quebec case earlier this year which approved some uses of private health insurance.

Since the ruling, provinces such as Alberta have been actively considering expanding the use of private health insurance.

The province is expected to announce by the end of October which private insurance firm will be chosen to conduct an actuarial study of the pros and cons of such a scheme.

Premier Ralph Klein has said allowing private insurance firms to sell policies would benefit Albertans who want to shorten their waiting times for non-emergency medical procedures.

However, the province has yet to define exactly what it means by “non-emergency.”

Bruera said he is “100 per cent sure” that private insurance would not improve palliative care.

“In general, services such as palliative care, that is not highly profitable or high tech, are generally not insured very well in the U.S.,” he said.

“If you privatize parts of the system, the juicy parts, the ones that are more profitable, will be taken by the private insurers. The most costly and less rewarding will be left for the government services.”

Des Moines Register: Separate health insurance from jobs

By REGISTER EDITORIAL BOARD
September 27, 2005

Your employer does not buy your groceries for you.

Your employer does not make your house payments for you.

Your employer does not pay your utility bills.

So why in the world is your employer expected to provide your health insurance?

Alone among the industrialized countries, the United States drifted into a cockamamie arrangement in which health insurance is job-based. The glaring flaws with such a system include complexity, confusion and gaps that leave 40 million Americans without insurance.

To those drawbacks add another: The soaring cost of job-based health insurance puts American companies at a disadvantage in global competition.

When U.S. companies move jobs to China or India or Mexico, they don’t get just cheaper labor. They escape the steep and rising cost of employee health care. It’s not the only reason U.S. manufacturing is threatened, but it’s a big factor. If America is going to retain a strong manufacturing base, it must level the playing field.

Manufacturers’ tab especially high

A study done for the National Association of Manufacturers looked at the built-in cost disadvantages U.S. companies face in the global marketplace. Employee benefits came in a close second to high corporate tax rates.

The disadvantage is especially felt by manufacturers, which traditionally have offered generous benefits. Health-care costs are one-third higher in manufacturing than in the service sector.

One reason is that venerable U.S. manufacturers pay health-insurance benefits to large numbers of retirees. As they have downsized their work forces, their retiree numbers have increased. Newer, service-sector companies aren’t burdened as much by these so-called legacy costs of retired workers.

General Motors says health-care costs for active and retired employees add $1,500 to the price of every car the company makes. That’s an expense the foreign competition doesn’t have.

Maytag Corp. in Newton is in a similar situation — a mature company that not only provides health benefits to its active work force but also helps retirees with prescription-drug benefits and Medicare supplements. In a message to employees earlier this year, Maytag noted that its worldwide work force decreased about 25 percent (from 24,000 to 18,000) between 2000 and 2004. During the same time, the number of retirees eligible for health benefits increased by 25 percent, to 7,000. Retiree medical benefits cost Maytag $60 million a year and are expected to reach $80 million by 2010. Nationally, it’s estimated that more than 9 million retirees get health benefits from their former employers.

Health insurance was a major issue in a 2004 strike at the Newton plant, as it has been in almost every labor dispute in America in recent years.

Universal system offers pluses

The needed action is obvious, if not easy. The cost of health care should be lifted from the shoulders of employers. It should be the responsibility of individuals and taxpayers.

Studies show that a universal, government-sponsored system — similar to those in every other industrialized nation — could cover everyone in America for about the same amount Americans now pay for a disjointed, job-based system. The bonus: It would improve the competitive position of American manufacturers.

The U.S. Department of Commerce last year published a white paper on competitiveness in manufacturing. It recommended attempting to lower health-care costs through measures such as joint purchasing and malpractice tort reform.

Unfortunately, manufacturers’ groups and the Commerce Department stop short of advocating comprehensive reform. It is not sufficient to tinker with a dysfunctional health-care system. Joint purchasing isn’t enough to get the job done.

The health-care-cost disadvantage borne by American manufacturers will be removed only by abandoning the whole idea of job-based insurance.

And only business has the lobbying clout to make it happen.

Manufacturers and other employers could break the gridlock over health-care reform by weighing in on the side of universal coverage that is not job-based. They need to do so for their own sake, the sake of competitiveness and the sake of the country.

Medicine's Sticker Shock (Kristof)

By Nicholas D. Kristof
The New York Times
October 2, 2005

In the aftermath of Hurricane Katrina, we have an opportunity to construct something far more important than higher levees – a national health care system that looks less like a tightrope and more like a safety net.

A dozen years after Bill Clinton’s health reform efforts were destroyed by the insurance industry’s duplicity, it’s worth trying again. The health care system is steadily becoming more gummed up in ways that are impossible to hide.

One of the bumper stickers attacking the Clinton plan read: “If You Like the Post Office, You’ll Love National Health Insurance.” That wouldn’t work today: the Postal Service runs a system that is manifestly more rational and efficient than our health care system. For starters, imagine a postal system that refused to deliver letters to or from 45 million Americans – except on rare occasions, by ambulance.

“This is one of those fleeting opportunities where a catastrophe creates an opportunity to rebuild something better than before,” says Dr. Irwin Redlener, president of the Children’s Health Fund and associate dean of the Mailman School of Public Health at Columbia University.

In a sign of the growing disenchantment with our health system, 13,000 doctors have joined Physicians for a National Health Program, which lobbies for a single-payer government-financed health program.

There are four main problems with the existing system. First, it leaves out 45 million uninsured Americans, and their number is rising. Second, it is by far the most expensive in the world, costing 15 percent of our national income, yet our outcomes are awful – U.S. life expectancy is worse than Costa Rica’s. Third, our business competitiveness is undermined when, for example, medical expenses add $1,500 to the sticker of each General Motors car. Fourth, our system is catastrophically inefficient: according to a study in The New England Journal of Medicine, health administrative costs are $1,059 per capita in the U.S., and just $307 in Canada.

A single-payer system would be most efficient but probably is not politically feasible at the moment. The smart new book “The Health Care Mess” suggests a variety of more gradual approaches that would face less opposition.

Whatever the mechanism, all children should be covered. It’s a disgrace that we use public funds to save the lives of nonagenarians but not those of 9-year-olds. And kids are a bargain: per capita medical spending is $1,525 for children less than 5, and $9,000 per person aged 65 to 74.

A second principle is that we should put less emphasis on curative medicine and more on public health and prevention – everything from preparing for avian flu to encouraging exercise. Sure, we can buy more “left ventricular assist devices,” which cost $210,000 per patient installed, or buy Erbitux for colon cancer, at $17,000 per month of treatment. But as a wise new book, “Prescription for a Healthy Nation,” argues, you get more bang for the buck when you promote healthier lifestyles – fighting obesity, cigarette smoking and the like.

Raising cigarette taxes saved far more American lives, for example, than an army of neurologists ever could. In the same spirit, I’d like to see a French-fry tax. And imagine the health gains if we banned potato chips and soda from schools.

Reforming the health system won’t be easy. In the real world, poor kids don’t see doctors not only because they’re uninsured, but also because Mom doesn’t have a car, can’t easily get time off from work, or doesn’t speak English. Those are hard nuts to crack – but one reason to think that we can do better is that much of the world does better.

I’ve been thinking of health care partly because of something that happened when I was on vacation in August. My kids and I were stacking firewood for my parents on the Yamhill, Ore., farm where I grew up, when suddenly the seven-foot stack collapsed – on top of my youngest. She was knocked down and pinned, her face bleeding, under a pile of logs.

I had insurance, and a car to get to the emergency room – and in the end the logs (stained with blood) turned out to be in worse shape than my daughter. She’s just fine. But that instant was heart-stopping in its terror – and the system routinely does fail such children in need. Isn’t it worth fighting one more time for reforms, so that we Americans can get health care every bit as good as Canada’s?

Canadian Physicians called to

Physicians: It’s in Your Court Now
By Steven Lewis

Canadian Journal of Nursing Leadership (CJNL), Vol 18, No. 3, 2005
http://www.longwoods.com/product.php?productid=17616

Abstract:
The Supreme Court decision of June 9, 2005 clarifies the political choice facing organized medicine in Canada.(1) Many of Canada’s doctors are strong and eloquent supporters of single-tier health care. Many are not, and never have been. A mere decade ago, at the CMA’s annual General Council meeting, a motion declaring that citizens “must have the right to choose regulated private insurance for all medical services” fell on a vote of 88 to 68.(2) Focus groups conducted by the CMA in 1996 revealed a wide chasm between the strong public support for public health care and the then 78% of physicians who believed stronger private-sector participation in health care was either very or somewhat acceptable.(3) And, of course, organized medicine was heatedly opposed to the introduction of medicare in Saskatchewan in 1962. More often than not, doctors’ organizations have strongly opposed measures that they have subsequently embraced. In this they are no different from any other privileged group – whatever their virtues, attunement to the will of the demos is not among them.

Article:

The profession’s support for single-tier health care has always been provisional, and it has been largely silent – one must infer approvingly so – on the growth of for-profit clinics. Some physicians have contracted out to the public system, others have plied their trade on both sides of the street and a few have abandoned medicare altogether. Until June 9, the debates among doctors were not central to the future of the system. Proponents of a private and parallel option had to chip away at medicare’s edges, abetted by a federal government that has been castigated by the Auditor General for refusing to enforce the Canada Health Act. Now “private and parallel” has the high court’s blessing, with a new twist: the legal buying and selling of insurance for medically necessary services. The court has tasered medicare; the question is now whether the system is temporarily stunned, or mortally wounded. CMA President Albert Schumacher declared the Supreme Court judgment “a stinging indictment of the failure of governments to respond to the mountains of studies that show we need real action on our health care system.” That we need real action on our health care system is incontestable. That government should be the exclusive or even principal target of indictment is the question on the table. The evidence suggests we should look elsewhere.

Governments fund health care and establish its general legislative and regulatory framework. Beyond that, the system is largely in the hands of physicians, who make the day-to-day decisions, prioritize patients, prescribe drugs, admit patients to and discharge them from hospital, order tests and carry out innumerable interventions with a remarkable degree of autonomy. They are not held accountable in any meaningful way for performance. They are indifferent, apparently, to the clinical practice guidelines produced by their own colleagues. There are huge variations in their practices that go unchecked, despite the obvious implications for quality and access.(4-7)

The “real action” needed on our health care system includes primary health care reform, a more rational division of labour, quality improvement and a remedy for inequities in pay scales that overvalue day-surgery assembly lines and undervalue geriatricians and rheumatologists. The call for these reforms has come largely from governments, and it has been thwarted or delayed not by governments but by doctors.(8) Both Romanow and Kirby noted the glacial advance of primary care reform. It is medical associations, not governments, that allocate incomes among specialties. Nurse practitioners, pharmacists and therapists are anxious to expand their scope of practice and to use their expertise fully. Try to find a government that disagrees. Try to find a medical association fully on board.

According to organized medicine, system failings are always someone else’s fault. Somehow Mr. Zeliotis’ hip surgery delay was caused by the nature and stinginess of the single-payer system. Nothing, apparently, is attributable to physicians retaining control over their individual wait lists and refusing to standardize criteria for assessing and prioritizing patients.(9) The failure to look for doctors with shorter wait times, to share responsibility for fairness and to participate in the kinds of process improvements that by 2003 got 88% of UK citizens into primary care within 48 hours of picking up the phone(10) is – government’s. If it’s government’s fault, it’s because government didn’t follow Whitehall’s lead and just say no to chaos.

Given its anarchic characteristics, it is bordering on miraculous that the system by and large serves most people well most of the time. The median wait time for cardiac surgery in Manitoba is 23 days.(11) Median wait times in British Columbia are well under three months for every surgical category except for corneal transplants (17 weeks), hip replacements (22 weeks) and knee replacements (28 weeks).(12) In Saskatchewan in 2004, 82% of surgeries were completed within six months, but 5% had wait times longer than 18 months.(13) And here is where the problem comes home to roost: if even as few as half of the 5% were waiting involuntarily, great harm was done.

Who is responsible? Governments don’t manage the wait lists. Governments are not responsible for following up, or not, with patients waiting for procedures. Governments do not decide that patient A will get served in two months while patient B, with identical needs, will wait 20 months. Doctors do. The Canadian long waits are not a capacity problem: simple arithmetic demonstrates that no one has to wait 18 months in a system where 4 out of 5 (or more) patients wait well under six months. But until recently the only response of organized medicine to these long waits was to cry poverty and enlist the public in government bashing. One would have thought the Hippocratic oath would have diverted some of this energy toward looking after the long-suffering. It does not take a cynic to observe that the long queues admirably served the purpose of extracting more money for health care – both public and private. And they also provided the pretext for Chaoulli, and here we are.

The history of medicare is a clash between the state’s goals of equity, order and efficiency with medicine’s goals of autonomy, growth and control. Society has made enormous concessions to organized medicine, such as the right of doctors to set up practice anywhere, the right to remain independent contractors rather than full partners in a complex system, freedom from the measurement, scrutiny and accountability of US-style managed care, and pay scales that vastly exceed those extant in the European systems the court and medicare’s critics selectively admire from afar. It has also encouraged governments to increase public spending by an astonishing 60% in the past eight years, an ongoing mea culpa for the four-year period in the last 35 when spending modestly declined. All the public expects in return is a shared commitment to single-tier equity, a willingness to participate in reforms and decent performance. Apparently this has been too much to ask.

Now, thanks to the Supreme Court, the legal underpinnings of the system have been dealt a blow, and the choices are starker for doctors. They can now openly abandon the public system and get in on the ground level of an emerging private insurance system catering to people with money. They can market the virtues of commodified medicine and concentrate on the sexy diagnostics and high-volume procedures under the guise of enhancing Canadians’ Charter rights. No more unlucrative sessions with the complex geriatric case. No more dealing with intractable chronic diseases. No more unrewarding encounters with the underclass. It’s an easy and pleasant $275,000 a year for family doctors at a clinic that bundles core services with the extras, charging $1,700 up front and $2,300 annually.(14) No doubt surgeons in the orthopedic and cataract centres can easily double and triple that income.

The Supreme Court has raised the stakes, and the public needs to know where official medicine stands. Will it accelerate public-system reforms, improve its performance and effectively preempt the market for private insurance? Or will it decant more care to the private sector, which, according to recent evidence from Australia’s hybrid system, increases public sector wait times?(15) Will it promote a fair income distribution so that graduating doctors no longer leave family medicine and geriatrics residencies unfilled while they flock to dermatology and orthopedics? Will it propose and participate in comprehensive wait-list management systems, like Saskatchewan’s, to ensure that no patient’s health is endangered by unmonitored waits and that those with greater needs get served first? Will it leap to the fore of the quality revolution, or continue to provide an endless source of material for the small-area-variation research industry?(16)

Perhaps, in its testily divided decision, the court has done the country a favour. We have not had a national, focused debate on where to draw the line on two-tier health care for decades, resorting to fictions about medically unnecessary services and ignoring the evidence under our very noses – most recently that for-profit long-term care facilities provide significantly less direct and support care to residents than their nonprofit counterparts.(17) Nor have we carefully and conclusively debated Tommy Douglas’s unrealized vision of a genuinely balanced continuum of care. Physicians have fought long and successfully to remain at arm’s length from the system. You wouldn’t get on a plane built by engineers who decided independently what parts to make and whether and how to fit them together. Why would anyone expect excellence from a health care system that is largely ungoverned and where mistakes and overuse trigger an avalanche of funding and income while prudent, efficient practice has the bracing effect of lowering one’s income?

This is not a time for hysteria or fear-mongering, but for self-examination, reflection and choice. How governments respond to the challenge is of course vitally important, and the political exchanges promise to be lively. But citizens and governments delude themselves if they imagine that a public system can succeed without a medical profession that is widely and officially committed to its values and more often than not promotes rather than resists constructive change.

For too long the rule of the game has been to spend more or lose physician support. We’ve spent more – a lot more – and the return on investment has been low. Canada is a country governed by elites. Will the medical profession rise to the challenge of creating a new and improved medicare, or will it, like so many elites, talk about the public interest but act in the interests of the few?

Steven Lewis is with Access Consulting Ltd., in Saskatoon, SK., and the Centre for Health and Policy Studies, University of Calgary, Calgary, AB.
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Footnotes
1. Chaoulli v. Quebec (Attorney General). 2005 SCC 35.

2. Sullivan P. Private health care dominates meeting as General Council calls for national debate. CMAJ 1995;153(6):801-3.

3. Sullivan P. Focus groups confirm that MDs, public differ on role of private health care. CMAJ 1996;154(8):1247-9.

4. Kennedy J, Quan H, Ghali WA, Feasby TE. Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces. CMAJ 2004;171(5):455-9.

5. Jaglal SB, Carroll J, Hawker G, McIsaac WJ, Jaakkimainen L, Cadarette SM, et al. How are family physicians managing osteoporosis? Qualitative study of their experiences and educational needs. Can Fam Physician 2003;49:462-8.

6. Brownell M. Tonsillectomy rates for Manitoba children: temporal and spatial variations. Healthc Manage Forum 2002;Suppl:21-6.

7. Katz A, DeCoster C, Bogdanovic B, Soodeen RA, Chateau D. Using administrative data to develop indicators of quality in family practice. Winnipeg: Manitoba Centre for Health Policy; 2004. Available: www.umanitoba.ca/centres/mchp/reports/pdfs/quality_wo.pdf (accessed 2005 Jun 20).

8. Medical Reform Group. Nearsighted physicians reject deal with government [media release]. Toronto: The Group; 2004 Nov 21. Available: www.hwcn.org/link/mrg/press.release.html#Nearsighted_Physicians_Reject_Deal_With (accessed 2005 Jun 20).

9. Sanmartin C, Shortt SED, Barer ML, Sheps S, Lewis S, McDonald PW. Waiting for medical services in Canada: lots of heat, but little light. CMAJ 2000;162(9):1305-10.

10. Department of Health. Achieving shorter waits: the PPF promises shorter waiting times across the service. London (UK): The Department; 2005. Available: www.dh.gov.uk/PolicyAndGuidance/PatientChoice/WaitingBookingChoice/WaitingBookingChoiceArticle/fs/en?CONTENT_ID=4066038&chk=ZurIX5 (accessed 2005 Jun 20).

11. Winnipeg Regional Health Authority. Health services wait time information: cardiac surgery. Winnipeg: Manitoba Health. Available: www.gov.mb.ca/health/waitlist/cardiac.html (accessed 2005 Jun 20).

12. Median wait times and wait lists. Victoria: Government of British Columbia; 2005 Mar 31. Available: www.healthservices.gov.bc.ca/cpa/mediasite/waittime/median.html (revised 2005 May 17, accessed 2005 Jun 20).

13. Wait time information. Regina: Saskatchewan Surgical Care Network. Available: www.sasksurgery.ca/wait-list-info.html (accessed 2005 Jun 20).

14. Copeman D. Interview with Don Copeman, Copeman Health Centre, Vancouver. Interviewed by Barbara Budd and Mary Lou Finlay, As It Happens [radio program]; 2005 Jun 1. Produced by the Canadian Broadcasting Corporation, Toronto. Available: www.cbc.ca/insite/AS_IT_HAPPENS_TORONTO/2005/6/1.html (accessed 2005 Jun 20).

15. Duckett SJ. Private care and public waiting. Aust Health Rev 2005;29:87-93.

16. Tu JV, Pinfold SP, McColgan P, Laupacis A. April 2005. Access to health services in Ontario: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences; 2005. Available: www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=2862&type=atlas (accessed 2005 Jun 20).

17. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, et al. Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter? CMAJ 2005;172(5):645-9.

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Acknowledgements
Reprinted from the Canadian Medical Association Journal 173(3): 275-77 by permission of the publisher. © 2005 CMA Media Inc.
Correspondence to: Steven Lewis, Access Consulting Ltd., 211-4th Ave. S., Saskatoon SK S7K 1N1; fax 306- 343-1071; steven.lewis@shaw.ca.

A Radical Healthcare Solution

Michael Hiltzik
LA Times
October 6, 2005

Business leaders, acting in what they regard as their economic self-interest, have torpedoed every attempt to improve the nation’s ridiculously ineffective healthcare system for decades. There hasn’t been a significant reform since Lyndon B. Johnson expanded Medicare and Medicaid in the 1960s.

The chickens are finally coming home to roost.Private industry assumed financial responsibility for employee healthcare after World War II. It no longer wants the burden. The crippling cost has been cited as a factor in the bankruptcies of United, Northwest and Delta airlines. Unscrupulous employers leave their workers medically stranded, thus undercutting competitors who try to do the right thing. (Think of the Wal-Mart effect in retail.)

The number of uninsured citizens is growing — more than a fifth of all non-elderly Californians, or 6.6 million persons, lack coverage — and the number of those insured whose benefits are being cut back by their employers is growing even faster.

So it shouldn’t be surprising that solutions once dismissed out of hand are suddenly getting a closer look. The most appealing is a single-payer system, which would replace today’s jigsaw puzzle of private insurance, public programs and nothing with a government-run healthcare program. In California, that option is being pushed by state Sen. Sheila Kuehl (D-Santa Monica), who says she senses growing, albeit still insufficient, support around the state after three years of proselytizing.

Kuehl’s plan is a work in progress. (She hopes to draft a full-fledged version next year.) Her basic proposal is for the state to finance comprehensive health coverage for all residents through a tax surcharge. Private insurers would be barred from selling equivalent coverage, but could market supplemental policies for services not on the state menu. An elected commissioner would establish benefits, set payments for providers, negotiate prescription drug deals, and so on.

Kuehl says her program would achieve universal coverage while cutting more than $8 billion from the medical costs of state government, employers and families, which are projected to reach $184 billion next year. (Her figures come from an analysis by the Lewin Group, a Virginia consulting firm, paid for by single-payer advocates.)

Hers is a radical solution. But many of the proposed alternatives in Sacramento merely involve letting insurance companies sell “affordable” strippeddown medical plans to workers. These remind me of my home earthquake policy, which won’t pay for most of the damage I might incur, but at least it’s cheap.

Critics of single-payer plans say they’re inefficient — the wait time for CAT scans in Canada averages a few months, to repeat a common rap on that country’s program. But such criticism assumes that the alternative is a system in which all patients have instant access to all the treatment they need. That system doesn’t exist in the United States, where even the insured can suffer long delays for diagnostic procedures and treatments, and the uninsured are lucky to get emergency room care.

Among single-payer’s virtues is that it cuts private insurers out of the loop. These companies exist largely to convert premium dollars into profits, sometimes at a rate of 10% or more. They win praise from Wall Street when they reduce the share of the premium dollar spent on medical treatment.

It’s true that the very notion of a government system gives some people the willies. “Considering our experience with having Congress run Medicare and Medicaid, I don’t think any physician or knowledgeable patient would say, let’s have them run it all,” says Jack Lewin, chief executive of the California Medical Assn. (He’s not connected to the Lewin Group.)

But the main objection doctors and hospitals have to those programs is that their reimbursements are too low. On the plus side, Medicare’s administrative costs are less than 2% of its benefit payments; for some private insurance plans, the ratio is 25%.

Still, even if one were to accept that a single-payer program would improve on the crumbling system we have today, there’s reason to doubt that it can work in a single state, even one with California’s immense bargaining power. As long as the rest of the country is operating by different rules, California will struggle with federal bureaucrats doing business the old way. (The state will need government waivers to absorb federally funded programs into its system.)
By replacing healthcare premiums with an employer-employee tax, Kuehl’s plan might reduce overall costs for employers who already offer comprehensive coverage, but it will raise costs for those that offer skimpy plans or none at all. This will anger small businesses and lobbyists for big skinflint companies. (Surprise: The California Chamber of Commerce has already labeled Kuehl’s proposal a “job killer.”) Such competitiveness issues can’t be solved except by nationwide healthcare reform.

Another concern is how the system will handle political pressure. Think it’s tough to close an urban firehouse? Wait until the state healthcare czar tries to close a neighborhood hospital. Of course, such decisions tend to be made now by insurance executives thousands of miles away; empowering a publicly accountable state official to weigh the pros and cons might be a step forward.

Kuehl’s plan isn’t perfect, but perfection is elusive in medicine, inside the hospital and out. It is an attempt to fix a failing system in one fell swoop, rather than with stopgap measures that will merely delay the reckoning. At the very least, it should focus the debate. As Kuehl told me this week, “We need to do more than nibble around the edges.”

U.S. cancer expert: Canadians aren’t aware of value of medicare system