PNHP

Montana Family Medicine Residency

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Montana Family Medicine Residency

The Coastal Research Group
Sixteenth National Conference on
Primary Health Care Access
April 10-12, 2005

The Eleventh J. Jerry Rodos Lecture:

Roxanne Fahrenwald, M.D., Director, Montana Family Medicine Residency:

“The man who says it cannot be done should not interrupt the man doingit.” Chinese proverb

http://www.coastalresearch.org/

Montana Family Medicine Residency:
http://www.aafp.org/residencies/240050001.html

Comment: For those of us frustrated with the relative lack of progress in our attempts at reforming health care, it is refreshing to hear an inspiring story for a change.

Very briefly, Dr. Fahrenwald reported on the successes in the past decade of the Montana Family Medicine Residency program. The program emphasizes equitable health care, including not only the insured but those without coverage or the resources to pay for care, and including those with access problems due to the rural distribution of a significant portion of the population. Training and services in mental health have been added to the program, not only because of current needs in Montana, but also to prepare family medicine physicians for their important role in improving mental health equity. The program ensures competencies in other clinical services, such as obstetrics, essential for rural communities without ready access to urban medical centers.

Quite gratifying is the fact that most of the physicians from this program go to regions where their services are needed, with many of them going to rural areas of Montana. Thus they are strengthening the primary care infrastructure that promotes quality improvement in a cost effective manner.

One concern is that the residency program has access to various funds that are not available to those in private practice. It can be very difficult for those physicians supporting health care equity if they cannot meet their expenses due to expanding problems with uninsurance and underinsurance. So we still need to establish equity in health care funding.

Which brings us back to the quote. We should not be deterred by those who say that comprehensive reform cannot be accomplished because it’s not politically feasible, even if such reform does make sense. We should ignore distracting interruptions as we move on with our task of establishing an equitable system of public financing of health care.

Dr. Fahrenwald recognized what she had to do and just did it. So can we. But, actually, we really do need the support of those who believe that reform makes sense. Maybe, instead, when they “interrupt” us, we should transform that encounter into an opportunity to include them in the process. With all of us working together, we can do it. By adhering to established principles of health policy science, all we have to gain is affordable, comprehensive, high quality care for everyone.

Health care goes south: Look to north(Denver Post)

By Jim Spencer
Wednesday, April 13, 2005

Ask investigative journalist Jim Steele if he is a scorned prophet because he claims the American health care system is terminally ill, and he says two words
:Canadian drugs.

Proof is everywhere that health care in the U.S. is in “Critical Condition,” as Steele and co-author Don Barlett titled their most recent book. But nothing bodes a health care revolution like Americans purchasing Canadian drugs.

Defying federal laws, states and cities have joined private citizens buying Canada’s affordable pharmaceuticals.

Changes in how this country organizes and pays for health care must come from the ground up, Steele said last week as he waited to address a fundraiser for the nonprofit group Health Care for All Colorado. The outlaw purchasing of prescription drugs paves the way for more radical steps.

“There’s a tremendous amount of mythology about the American health care system,” Steele said. “This country has talented people who can provide the best care in the world. But in Canada, if you get sick, you don’t run the risk of losing your house. Here, you do.

“You have freedom of choice to choose your doctor in Canada and Europe. Here, your insurance company cuts deals with doctors and hospitals and sometimes tells you where to go.”

In their book, whose complete title is “Critical Condition: How Health Care in America Became Big Business and Bad Medicine,” Steele and Barlett don’t stump for any specific country’s medical delivery system. Rather, they call for an overhaul of the American model.

The authors suggest a quasi-public United States Health Council, modeled organizationally after the Federal Reserve. The council would standardize health insurance and guarantee at least minimal health care to all Americans.

“We spend a higher percentage of our national wealth on health care than anyone in the world,” Steele said. “And yet we don’t live as long as most of (the world’s industrialized countries).

“This problem doesn’t require more money. We need to redirect what we’re already spending.”

An attempt to make medical care more efficient and affordable by applying market principles is so far past the point of diminishing returns, said Steele, that human suffering now grows nearly as fast as costs.

In a 2004 survey, said Steele, the Center for Studying Health System Change detected a “marked shift” in the willingness of doctors to allow government involvement in reforming health care.

That’s because “a sizable percentage of our population lives outside the health insurance system,” Steele said. “A sizable percentage is underinsured.”

In researching “Critical Condition,” Steele and Barlett found many Americans one illness from financial ruin.

A recent study showed that medical bills played a role in a third of all personal bankruptcies.

Things are getting worse, said Steele. Because of rising costs in medical care, fewer small businesses can afford employees’ health insurance. At the same time, large companies are cutting health benefits while increasing employees’ portions of premiums.

“We have created a monumental bureaucracy in health care,” said Steele. “Some studies say one out of every three dollars goes to bureaucracy.”

This bureaucracy siphons millions of dollars that should be spent on actual treatment. Instead, said Steele, doctors and hospitals spend a fortune trying to get reimbursed by hundreds of insurance plans with different rules.

A single-payer health care system or standardization of insurance companies’ coverages may not yet resonate with U.S. politicians or voters, said Steele. But most Americans are painfully aware of health insurance “customer service” representatives trained to stonewall people trying to get their medical bills paid.

As soon as an affordable alternative to that runaround becomes available, people will latch on to it faster than a cheap dose of Canadian drugs.

And the revolution will continue.

Jim Spencer’s column appears Monday, Wednesday and Friday. He can be reached at 303-820-1771 or jspencer@denverpost.com.

Private plans haven't delivered the cure

The Orange County Register
April 10, 2005
Private plans haven’t delivered the cure
By Don R. McCanne, M.D.

Bruce Bodaken, CEO of Blue Shield of California, warns that, unless we reduce health-care costs and provide coverage for the uninsured, we will likely turn to a government-run single-payer system [“‘Vicious cycle’ of care,” Business, March 30].

That raises two questions. Why hasn’t Bodaken’s own industry been able to solve the problems during the past half-century that it has had control of health care spending? And what is there about a single-payer system that would cause policy-makers to turn to that option?

Private health plans should be providing us with higher quality at lower cost. But by most measures, we are receiving relatively mediocre care that is rife with error and wasteful excesses, while many are not receiving even the most basic essential services. And over 90 percent of Americans agree that health care costs are out of control. Since private plans are failing us on cost and quality issues, are there any other reasons to keep them in charge?

Do private plans avoid the inherent waste of government bureaucracies?Unfortunately, private plans actually consume a far greater percentage of health care dollars in administrative costs than do public programs such as Medicare. And worse, our fragmented system of funding care places a tremendous,wasteful administrative burden on the providers of health care.

Bodaken exemplifies this inefficiency in admitting that he can’t figure out the benefits of his own personal health plan provided by his own company. Do private plans provide us with choice? The American Medical Association just released a report confirming, by Justice Department standards, that 93 percent of HMO/PPO markets are “highly concentrated.” So much for true market choice of health plans. Besides, the choice we really want is choice of our own physicians and hospitals. Most private plans limit our choice and assess severe financial penalties for failing to use their preselected choices.

If we leave the plans in place, what options do we have? Everyone agrees that the status quo will never do since costs are skyrocketing, access is diminishing and quality is not improving.

Should we relax regulatory oversight, allowing the markets to work more effectively? We know that the plans invariably attempt to sell to the healthy and avoid the sick. That might be appropriate for the marketplace, but it shifts the burden of risk from the plans to the taxpayers.

Should we instead increase regulatory oversight? Requiring that plans jointly guarantee affordable coverage for everyone would create a de facto single-payer system since the plans then would provide primarily only the administrative services that we actually do need for health care financing.

The $1.9 trillion that our nation is already spending on health care is more than enough to pay for comprehensive health care services for everyone. But there is an urgent need for us to demand much more accountability for our health care spending. Just don’t expect it to come from the health plans.

http://www.ocregister.com/ocr/2005/04/10/sections/commentary/READER%20REBUTTALS/article_474432.php

Private plans haven’t delivered the cure

The Orange County Register
April 10, 2005
Private plans haven’t delivered the cure
By Don R. McCanne, M.D.

Bruce Bodaken, CEO of Blue Shield of California, warns that, unless we reduce health-care costs and provide coverage for the uninsured, we will likely turn to a government-run single-payer system [“‘Vicious cycle’ of care,” Business, March 30].

That raises two questions. Why hasn’t Bodaken’s own industry been able to solve the problems during the past half-century that it has had control of health care spending? And what is there about a single-payer system that would cause policy-makers to turn to that option?

Private health plans should be providing us with higher quality at lower cost. But by most measures, we are receiving relatively mediocre care that is rife with error and wasteful excesses, while many are not receiving even the most basic essential services. And over 90 percent of Americans agree that health care costs are out of control. Since private plans are failing us on cost and quality issues, are there any other reasons to keep them in charge?

Do private plans avoid the inherent waste of government bureaucracies?Unfortunately, private plans actually consume a far greater percentage of health care dollars in administrative costs than do public programs such as Medicare. And worse, our fragmented system of funding care places a tremendous,wasteful administrative burden on the providers of health care.

Bodaken exemplifies this inefficiency in admitting that he can’t figure out the benefits of his own personal health plan provided by his own company. Do private plans provide us with choice? The American Medical Association just released a report confirming, by Justice Department standards, that 93 percent of HMO/PPO markets are “highly concentrated.” So much for true market choice of health plans. Besides, the choice we really want is choice of our own physicians and hospitals. Most private plans limit our choice and assess severe financial penalties for failing to use their preselected choices.

If we leave the plans in place, what options do we have? Everyone agrees that the status quo will never do since costs are skyrocketing, access is diminishing and quality is not improving.

Should we relax regulatory oversight, allowing the markets to work more effectively? We know that the plans invariably attempt to sell to the healthy and avoid the sick. That might be appropriate for the marketplace, but it shifts the burden of risk from the plans to the taxpayers.

Should we instead increase regulatory oversight? Requiring that plans jointly guarantee affordable coverage for everyone would create a de facto single-payer system since the plans then would provide primarily only the administrative services that we actually do need for health care financing.

The $1.9 trillion that our nation is already spending on health care is more than enough to pay for comprehensive health care services for everyone. But there is an urgent need for us to demand much more accountability for our health care spending. Just don’t expect it to come from the health plans.

http://www.ocregister.com/ocr/2005/04/10/sections/commentary/READER%20REBUTTALS/article_474432.php

Committee passes single-payer universal health insurance plan(Vermont Times Argus)

By John Zicconi Vermont Press Bureau

MONTPELIER A House committee comprised largely of Democrats on Friday adopted a health-care reform plan that restructures key parts of state government to lay the groundwork for a publicly financed, universal-care system paid for with taxes.

The plan calls for primary and preventative care coverage for all Vermonters by July 2007, publicly funded hospital coverage by October 2007, and universal coverage for other medical needs no later than July 2009.

The proposal was immediately criticized by physicians, hospital officials and insurance executives because the proposal calls for sweeping changes to Vermont’s health-care delivery system without saying how much it would cost or what medical procedures would be covered.

Those decisions were put off until next year to allow lawmakers more time to meet with business leaders, health-care officials and Vermont residents to understand better what coverage level they desire and how much they are willing to pay.

“This is a big two step,” said Rep. John Tracy, D-Burlington and chairman of the House Health Care Committee. “This summer and fall is the time for people to have that discussion.”

Governor James Douglas, a Republican, did not wait to blast the proposal.

“When Vermonters take a good hard look at what the House Democrats are proposing they’re going to want a second opinion,” said Douglas, who believes the plan will increase income taxes 134 percent and lead to health-care rationing.

“This plan would dramatically raise taxes and put health care decisions in the hands of politicians and government bureaucrats,” said Douglas, “a prospect I fundamentally and unequivocally oppose.”

Asked if he would veto the bill if it reached his desk unchanged, Douglas dodged the question but said: “I think I am sending a pretty clear message.”

Douglas prefers a much less ambitious approach to health care reform that focuses more on changes to the insurance industry than creating new government programs.

The House Health Care Committee voted 9-2 in favor of the bill. Two of the panel’s four Republicans Christopher Louras of Rutland City and Joseph Baker of West Rutland opposed the measure, which must be reviewed by at least one other House committee before advancing to the floor for debate.

The Senate must also approve the proposal.

Sen. James Leddy, D-Chittenden and chairman of the Senate Health and Welfare Committee, declined to offer an opinion because he had not read the bill. But those who represent Vermont physicians, insurance companies and hospitals criticized the measure.

“We cannot live with this,” said Beatrice Grause, executive director of the Vermont Association of Hospitals and Health Systems who just two weeks ago called an earlier draft of the bill a good first step.

“I’m concerned that the committee’s approach uses over regulation,” Grause said. “To control cost, health-care delivery has to be engineered. And that requires innovation not more regulation.”

The plan calls for the immediate reorganization of state government to create a stand-alone Department of Health Care Administration that will oversee health care regulation, planning and cost control.

Strategies include global budgets for hospitals that are capped at redetermined inflation rates and physician payments that limit the growth of health-care spending. The goal is to lower Vermont’s health-care growth rate from more than 12 percent annually to about 7 percent, committee members said.

The proposal calls for a special panel of House and Senate members to annually decide what medical services the public-system will pay for. Private insurance, either personally purchased or supplied by an employer, would pay for services that are not included.

The plan does not spell out what public coverage would cost and which taxes would be used to pay for it, but committee members said a combination of income and a payroll taxes were the likeliest candidates.

The bill calls for a tax study to make exact recommendations. It also calls for an economic-impact study to determine the affect raising taxes would have on employers, Vermont’s business climate, and the state’s cost of living.

Physicians and insurance officials criticized the plan for setting implementation dates, promising universal coverage and ordering government reorganization before knowing what these impacts will be.

“Do the studies and find out what they say, then determine your direction,” said Leigh Tofferi, spokesman for Blue Cross Blue Shield of Vermont, the state’s largest health care insurance company. “There is no information right now that the new system will be an improvement.”

House Speaker Gaye Symington, D-Jericho, defended the committee’s approach.

“Vermont needs to move forward with this conversation and we can’t do that without putting something on the table to react to,” Symington said. “They have articulated a vision on where they want to go, outlined steps to get there and are inviting Vermonters to come and tell them what they think.”

Baker, the West Rutland Representative who voted against the bill, said he had already heard enough from physicians and others to convince him the proposal was taking the wrong direction.

“What bothered me is I saw fear in some people’s faces,” Baker said. “If we are willing to see fear in people’s faces we are doomed to fail.”

Contact John Zicconi at john.zicconi@timesargus.com or john.zicconi@rutlandherald.com

What good is health care without food or housing?

The New York Times
April 8, 2005

U.S. Plans New, Deep Cuts in Housing Aid
By David W. Chen

If the changes sought by the administration take effect, they will result in one of the biggest cuts since Washington first began subsidizing housing: as much as $480 million, or 14 percent, of the $3.4 billion federal budget for day-to-day operations, including labor, maintenance, insurance and utilities, at the nation’s 3,100 housing authorities.

“I’ve never seen anything this devastating occur in public housing,” said Stephanie W. Cowart, executive director of the Niagara Falls Housing Authority.

Michael Liu, HUD’s assistant secretary for public and Indian housing, said in an interview that housing agencies had been warned for months that “there was always the possibility of changes,” especially “in an era of tight budgets on the domestic front.”

“For a housing authority that has been on a particular diet for, say, 40 years, facing a different kind of diet, cutting out fats and sugars and other stuff that tastes good – well, it’s tough to change, and that’s a natural reaction,” he said. “But in the long run, it’s going to make us more effective, more efficient.”

“I’m confident that those who are concerned, once they sit down, they’ll get over it, and deal with it,” Mr. Liu said.

And…

Hunger-Based Lines Lengthen at the Faith-Based Soup Kitchens By Francis X. Clines. The sight of masses of Americans gratefully chowing down on free food
is indeed a show, an amazingly discreet one that is classified not as outright hunger but as “food insecurity” by government specialists who are busy measuring the growing lines at soup kitchens and food pantries across the nation. There were 25.5 million supplicants regularly lining up in 2002; they were joined by 1.1 million more the next year. And even more arrive as unemployment and other government programs run out.

Most immediately, food charities are pleading against further cuts in the federal emergency food and shelter program, which directly fights hunger. Last year, 48 soup kitchens closed in the city as supplies were exhausted, and hundreds of others reported to be making do by cutting back on daily portions.

Beyond that, however, administrators know that the myriad of severe program cuts looming in Washington – for everything from low-income wage supplements
to health care spending for poor people – can only lead to further cuts down the revenue food chain in statehouses and city halls and, finally, longer lines of people silently begging for food.

Comment: How could politicians possibly understand the need for a universal health program if they don’t even understand the need for basic housing and food? Or did the majority of Americans support these policies at the polling booths? If so, have they no shame?

Projected increases in the uninsured

Health Affairs
April 5, 2005
It’s The Premiums, Stupid: Projections Of The Uninsured Through 2013
By Todd Gilmer and Richard Kronick

Abstract:
Increases in the cost of health care from 1979 to 1999 accounted for the decline in health insurance coverage that occurred during that time period, as our earlier work demonstrated. Here we examine whether the model we presented adequately accounts for the observed changes in health insurance
coverage from 1999 through 2002, and we show that the model accurately
predicted the increase in uninsured people during that time period.

Using the model and projections for national health spending, we project that
the number of nonelderly uninsured Americans will grow from forty-five million
in 2003 to fifty-six million by 2013.

From the Discussion:
In 2001 we published a paper titled “The Calm Before the Storm,” projecting
that the number of uninsured Americans would increase rapidly as a result of
health insurance premiums rising more rapidly than personal incomes. It is clear that a full-force storm blew in from 1999 to 2002 and that the actual path of the percentage uninsured… followed the path we expected based on our estimated relationships between affordability and coverage.

We expect the storm to continue during the next decade. However, based on
CMS spending projections, its ferocity will lessen. The CMS predicts that health spending for insured people under age sixty-five will grow 2.4 percent per year faster than personal incomes from 2002 to 2013. At this “moderate” rate of spending growth, we expect that the number of uninsured people will increase “only” thirteen million over the next decade from its 2002 level, or eleven million from the estimate of forty-five million uninsured people in 2003. Based on estimates from the Institute of Medicine, this will lead to an increase of 4,500 deaths annually and to an increased annual loss of human capital of $16-$32 billion. If the estimated growth rates for health care prices and income are wrong (as they almost certainly are), it seems much more likely to us that affordability will decline more quickly than expected rather than more slowly, and it seems more likely that the number of uninsured people will increase more quickly than projected rather than more slowly.

It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance coverage requiring contributions from some combination of employers, employees, and taxpayers. It is also unlikely that either our current system of employer-sponsored coverage or an alternative system of universal coverage will be sustainable without more effective efforts at cost containment.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.143

Comment: Professors Gilmer and Kronick have provided objective evidence of
what we instinctively knew. Lack of affordability of insurance premiums has
prevented tens of millions from being covered, and, without major change, the problem will only get worse. A few comments are warranted.

The term “affordability” is often avoided by economists because it is not well defined and includes an element of subjectivity based on varying opinions on what is and what is not affordable. Gilmer and Kronick have demonstrated that there is a degree of objectivity in the concept of affordability since the
“affordability index” (per capita health spending for nonelderly insured adults divided by the median income of nonelderly adult workers) does correlate quite predictably with the percentage uninsured among nonelderly workers. This article provides us with credibility when we state that health care is becoming less and less affordable.

This article also provides us with a prediction of what would happen if we were able to bring the rate in growth of health spending down to the rate of inflation, assuming no other structural reform of health care financing. They project that an additional 13 million will be without insurance in 2013. Of those, 4.4 million would be due merely to the increase in the population, whereas 8.6 million would be due to a further deterioration in affordability. Though many suggest that all will be well if we merely control health care costs, the numbers of uninsured would still expand by 4.4 million. Obviously structural reform must involve more than merely containing costs.

Another crucial point is that the authors’ model implicitly assumes that health insurance premiums will continue to purchase coverage that would provide financial protection against significant medical losses. Unfortunately, current trends could change their model. Competition based on premiums is resulting in a shift of risk to patients. Reports such as the recent Harvard bankruptcy study are demonstrating that we are facing an epidemic of underinsurance. Although this could reduce the upward pressure on premiums and lessen the growth in the uninsured, it could also have the paradoxical affect of causing even more to drop coverage when they recognize that it no longer protects against financial catastrophe. Why invest large sums in insurance premiums when major illness will drain all of your resources anyway?

Gilmer and Kronick are quite right that we need both universal coverage and
more effective cost containment. But our current demand side efforts utilizing private plans can only increase the problem of underinsurance and affordability of health care. We need to change to supply side economics if we expect to have affordable, comprehensive care for everyone.

A single payer system, by design, is universal, comprehensive, and utilizes supply side mechanisms to contain costs. In the United States, the $6423 per
capita that we are already spending on health care supplies some of us with too much care that is not beneficial, while leaving many with unmet needs. But we won’t get our spending right until we decide to adopt supply side funding of a universal system. It won’t be perfect (no system is), but it’ll be vastly superior to what we have.

Or we can continue to do nothing. The lack of insurance will then cost us 22,500 nonelderly adult lives per year. Is that a price that we are willing to pay for our inaction? Before grumbling about another stupid rhetorical question, think about the consequences of merely walking away and going about your usual business. Tens of thousands of people will continue to die.

Kitzhaber and Reinhardt on life, death and Congress

The Christian Science Monitor
April 04, 2005
Congress’ implicit healthcare rationing
By John Kitzhaber

As an emergency physician and former governor, I am struck by the towering contradictions – and indeed the hypocrisy – in the controversy over the tragic plight of Terri Schiavo. On the same day that the US House of Representatives voted to involve the federal courts in her case, it also approved a 10-year $92-billion cut in Medicaid funding – $30 billion deeper than the cut recommended by President Bush.

The relationship between these two decisions – virtually unreported by most media – goes to the very heart of why we’re unable to resolve the growing crisis in our healthcare system. While involving the federal courts in an attempt to save the life of one highly visible individual, Congress made a fiscal decision that will deny thousands of other Americans timely access to healthcare, some of whom may die as a result.

http://www.csmonitor.com/2005/0404/p09s02-coop.html

And…

The Daily Princetonian
April 1, 2005
Seeking to understand life, death
By Uwe Reinhardt

Terri Schiavo dies, reads the Washington Post’s news alert on my desktop. After gradually starving her to death, in accordance with American law and our jurists’ interpretation thereof, Schiavo finally has left us.

Unwittingly, she has helped us understand, once again, what a confused, ill-informed, sometimes opportunistically cynical, but ever bizarre nation we are.

Let us start with the seemingly pious politicians and pundits who saw in this case an opportunity to proclaim the sanctity of human life. Really? In a recent series of books on the plight of the millions of Americans without health insurance, the medical and social scientists working with the prestigious institute of Medicine of the U.S. National Academy of Sciences reminded the nation that 18,000 people die each year as a direct result of the lack of health insurance, making it the sixth leading cause of death among people aged 25-64, after cancer, heart disease, injuries, suicide and cerebral vascular disease, but before HIV/AIDS or diabetes. The nation’s infant mortality rate is one of the highest in the OECD nations. Citing the CIA Fact Book 2005, economics professor Alan Krueger reminds us in The New York Times (March 31) that our infant mortality rate is higher even than Cuba’s.

It can fairly be asked what the pundits and politicians who waxed so pious on the sanctity of Schiavo’s life have ever done to avoid this tragic, avoidable loss of human life in the rest of America. If we searched their records, we would discover that many and probably most of them either have countenanced that loss with equanimity, doing little to avoid that loss, or, worse still, have opposed as “socialism” any attempt to provide health insurance to all American children and, indeed, to all people living in this land.

http://www.dailyprincetonian.com/archives/2005/04/01/opinion/12531.shtml

Comment: For Congress to hear, voices must speak.

More Than One In Four Workers Will Be Uninsured In 2013

EMBARGOED for release
Tuesday, April 5, 2004, 12:01 EDT

Contact: Jon Gardner
jgardner@projecthope.org
301-347-3930

More Than One In Four Workers Will Be Uninsured In 2013

As Coverage Becomes More Unaffordable, Health Affairs Article Says

Researchers Base Findings On Relationship Between Growth In Health Care Spending And Personal Income

BETHESDA, MD�More than one in four American workers under age 65 will be uninsured in 2013 (nearly 56 million people); the increase will be driven by workers� increasing inability to afford health insurance, according to new projections posted today on the Health Affairs Web site.

Authors Todd Gilmer and Richard Kronick of the University of California, San Diego, base their estimates of the uninsured on federal projections of health spending, personal income and other population characteristics. Their work was supported by the California HealthCare Foundation.

Because growth in per capita health spending is expected to outpace median personal income by 2.4 percentage points per year, health care coverage will continue to decline, because more Americans will find it unaffordable. While factors such as changes in employment patterns and demographic shifts have some mild effects on health care coverage, cost has the biggest effect.

For each 1 percent increase in health spending relative to personal income, the number of uninsured people increases by 246,000, the researchers say. As a result, according to their projections, 11 million more people will lack coverage in 2013 than in 2003. Based on estimates from the Institute of Medicine, this is expected to lead to an increase of 4,500 deaths annually and an increased annual loss of human capital of $16-$32 billion.

�Regardless of whether health care benefits are being paid out of employer�s or employee�s pocket, and without regard to the amount of premium contribution that employees are required to make, there is a remarkably tight relationship between affordability and coverage rates,� the authors say.

�It is unlikely that we will be able to solve the problem of the uninsured without some form of universal health insurance requiring contributions from some combination of employers, employees, and taxpayers,� they continue. �It is also unlikely that either our current system of employer-sponsored coverage or an alternative system of universal coverage will be sustainable without more effective efforts at cost containment.�

The authors add that the accuracy of their estimates of health care coverage will depend on how closely actual health spending and personal income mirror the federal government�s projections.

The ten-year projections show a smaller differential between health care spending and personal income than in the recent past. Between 1999 and 2002, per capita health care spending spiked 9.8 percent a year while median personal income rose only 2.2 percent. As a result, the authors say, uninsurance among nonelderly workers rose 1.5 percentage points, from 22.3 percent in 1999 to 23.8 percent in 2002.

Gilmer is an assistant professor in the UCSD School of Medicine�s Department of Family and Preventive Medicine. Kronick is a professor in that department and chief of the Division of Health Care Sciences at UCSD.

You can read the article at content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.143.

Health Affairs, published by Project HOPE, is the leading journal of health policy. Peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.

The full text of this Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will revert to pay-per-view for nonsubscribers. The abstracts of all articles are free in perpetuity. Support for the publication of this Web Exclusive was provided by the California HealthCare Foundation; Web Exclusives are also supported in part by a grant from the Commonwealth Fund.

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Where's outcry over the lack of health care?(Baltimore Sun )

Letters to the Editor
Originally published April 2, 2005

Where’s outcry over the lack of health care?

The Terri Schiavo case cut to the core of American hearts and souls. In part, the outpouring of passionate support for her parents’ position was about the individuals involved. In a larger sense, it was about deep concerns many Americans have about the direction our moral life is taking (“As Schiavo saga winds down, leaders pursue broader debate,” March 29).

But one aspect of this moral tension that was not given full consideration in the Schiavo case is access to medical care. More than 45 million Americans lack health care insurance. The Institute of Medicine has estimated that the lack of health insurance is the direct cause of death for more than 18,000 Americans every year.

These 18,000 Americans die because of complications from very treatable diseases, such as hypertension and diabetes. In the Schiavo case, there was conflicting evidence as to whether Terri Schiavo would have wanted to continue chronic tube feedings with her degree of brain damage.

There is absolutely no conflicting evidence about the 45 million Americans who are excluded from health care insurance. They want it, and reside in a nation that denies it to them.

There is absolutely no moral ambiguity about the 18,000 Americans who are sentenced to death every year because our health care system refuses to address their needs.

Why is there no moral outcry about these Americans who unnecessarily die every year? Do they matter as much as Mrs. Schiavo? Where is emergency action by our president and our Congress? Where is the righteous rage from those who fear God?

Terri Schiavo’s care cost, at a conservative estimate, $100,000 per year for 15 years. How many Americans could have been kept alive if equal monies had been spent in treating routine diseases? How can our president and Congress try to pass budget cuts for Medicaid at a time when lack of health insurance benefits is pushing more and more workers into Medicaid?

Does the suffering of millions of the working poor have any meaning to our leaders? I have a deep respect for Christians who saw vital moral issues in continuing the tube feedings for Terri Schiavo. I pray they will be equally able to see the vital moral issues in caring for everyone who needs medical care.
Terri Schiavo’s greatest gift to her country may be in wakening its conscience.

Dr. James A. Cockey
Salisbury

Where’s outcry over the lack of health care?(Baltimore Sun )

Letters to the Editor
Originally published April 2, 2005

Where’s outcry over the lack of health care?

The Terri Schiavo case cut to the core of American hearts and souls. In part, the outpouring of passionate support for her parents’ position was about the individuals involved. In a larger sense, it was about deep concerns many Americans have about the direction our moral life is taking (“As Schiavo saga winds down, leaders pursue broader debate,” March 29).

But one aspect of this moral tension that was not given full consideration in the Schiavo case is access to medical care. More than 45 million Americans lack health care insurance. The Institute of Medicine has estimated that the lack of health insurance is the direct cause of death for more than 18,000 Americans every year.

These 18,000 Americans die because of complications from very treatable diseases, such as hypertension and diabetes. In the Schiavo case, there was conflicting evidence as to whether Terri Schiavo would have wanted to continue chronic tube feedings with her degree of brain damage.

There is absolutely no conflicting evidence about the 45 million Americans who are excluded from health care insurance. They want it, and reside in a nation that denies it to them.

There is absolutely no moral ambiguity about the 18,000 Americans who are sentenced to death every year because our health care system refuses to address their needs.

Why is there no moral outcry about these Americans who unnecessarily die every year? Do they matter as much as Mrs. Schiavo? Where is emergency action by our president and our Congress? Where is the righteous rage from those who fear God?

Terri Schiavo’s care cost, at a conservative estimate, $100,000 per year for 15 years. How many Americans could have been kept alive if equal monies had been spent in treating routine diseases? How can our president and Congress try to pass budget cuts for Medicaid at a time when lack of health insurance benefits is pushing more and more workers into Medicaid?

Does the suffering of millions of the working poor have any meaning to our leaders? I have a deep respect for Christians who saw vital moral issues in continuing the tube feedings for Terri Schiavo. I pray they will be equally able to see the vital moral issues in caring for everyone who needs medical care.
Terri Schiavo’s greatest gift to her country may be in wakening its conscience.

Dr. James A. Cockey
Salisbury

Minnesota Medical Association’s universal insurance bill

Star Tribune
March 30, 2005
Bill mandates health coverage for Minnesotans
By Patricia Lopez

Every Minnesotan would be required to have at least minimal health insurance and every insurer would have to offer such a plan under a far-ranging health care overhaul bill offered by the Minnesota Medical Association on Tuesday… which was introduced with bipartisan support in the House and Senate…

Dr. Michael Gonzalez-Campoy, MMA president, said that the plan was the result of “months of work,” and that health providers briefed on it had been enthusiastic.

At its core, the plan would set out an as yet undefined set of “essential benefits” that would provide minimal coverage with an emphasis on prevention.

Dr. Judith Shank, a dermatologist and former MMA president who led the organization’s health reform committee, said that while no guarantee of a subsidy exists in the bill, there is a presumption that “there would have to be subsidies for people who cannot afford” even the essential benefits coverage on their own.

Some additional money would come from the thousands of young people who are uninsured either by chance or choice. Shank has argued that “it is unfair for people who assume they are young and healthy to opt out” of health insurance, as some do. By requiring them to have some type of coverage, risk would be spread as broadly as possible, she said.

(Sen. Sheila) Kiscaden said that under the bill Minnesotans might be required to offer proof of coverage when they filed their income taxes or applied for a driver’s license. By the same token, insurers would have to offer the essential benefits and could not reject anyone because of age, gender or health history. Preexisting health conditions, a common reason for rejection for traditional policies, could not be taken into account.

Gonzalez-Campoy said the mandatory requirement would bring another 374,000 uninsured Minnesotans into the system, resulting in earlier treatment, more prevention and more affordable care. Ultimately, he said, “health care costs will be lower.”

http://www.startribune.com/stories/587/5318643.html

Comment: The Minnesota Medical Association and the Minnesota state legislature are to be commended for placing comprehensive health care reform on the political agenda. My critique of their proposal should not be allowed to detract from their sincere support of much needed reform. But we should look at what their “months of work” on the policy issues has produced.

The plan begins with a core of “‘essential benefits’ that would provide minimal coverage” for everyone. But this presumes that there are additional beneficial health care services to which lower-income individuals are not entitled. Rather than defining a core of basic benefits, it would be more appropriate to define those health care services that should not be universally accessible.

Once you list items such as vanity cosmetic surgery or hospital penthouse suites, it becomes more difficult to define the care that you would deny. Since the purpose of reducing access to care is to control spending, it would be much more rational to use mechanisms that shift spending from useless or detrimental services to spending on all beneficial services for everyone. The spending on useless administrative services, on high tech excesses, and on other inappropriate services have been estimated to be 50% of our health care budget. Single payer policies would recover more of that waste than would be required to pay for the current gap in universal access to beneficial services.

Perhaps the most difficult political hurdle is to broker an agreement on how you pay for universal coverage. Acknowledging that subsidies will be necessary for people who cannot afford even the essential benefits is important, but there already is near universal agreement on that point. Leaving funding out of the bill reveals the fear of advancing a proposal that involves the government and taxes. Again, there is agreement across the political spectrum that reform must involve both government and taxes since there is no other way to equitably fund access to reasonably comprehensive services. That bull is charging us, and we have no choice but to grab it by the horns… now!

It would be nice to believe that a significant source of funding would be the young and healthy who are uninsured by choice. But since most of them actually are uninsured because they cannot afford coverage, no juice will be forthcoming from that turnip. For the few free riders who can afford to pay, an equitable system would ensure their compliance.

Requiring individuals to offer proof of coverage is the equivalent of requiring uninsured individuals to pay for their own coverage (individual mandate), an impossibility for those who do not have the funds yet fall above the levels qualifying for subsidies. An effective policy would be to automatically cover everyone, then the need to provide proof of coverage would be eliminated.

With our current system of multiple private plans, community rating and guaranteed issue drive up premiums, making plans unaffordable for those with low or even modest incomes. Again, the problems of community rating and guaranteed issue would be eliminated by the adoption of a single payer system.

The primary reason for providing comprehensive coverage for the uninsured is that it does improve health care outcomes. But does it really save money? Earlier intervention does prevent spending on some more expensive interventions that would otherwise result from deferred access to essential care, but there is an offset through the costs of improved access to care.

Although the net financial impact is difficult to quantify, any savings would not be enough to rely on to fund the gaps in coverage. Either we will have to spend much more money, or we will have to adopt a system that spends what we already have much more effectively, providing us with greater health care value. Of course, that’s what a single payer system is all about.

Another quote from this article is appropriate:

“Rep. Jim Abeler, R-Anoka, the bill’s House sponsor, said that even if the MMA proposal does not pass this year, it ‘puts a whole lot of ideas on the table for us to look at.'”

We just hope that their aversion to politically charged policies do not prevent them from looking at all policy options, including those that would provide affordable, comprehensive health care coverage for everyone.