PNHP

Who Uses Emergency Departments?

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Who Uses Emergency Departments?

Poor Health, Not Lack of Primary Care or Medical Insurance Found to Drive Emergency Visits
American College of Emergency Physicians
News Release – October 18, 2004

The first large-scale study of its kind finds the majority of individuals who use emergency departments have a usual source of care, medical insurance and are not poor. The biggest factor driving people to seek emergency care is poor physical and mental health…

In this study, based on a sample of nearly 50,000 adults interviewed between 2000 and 2001, 83 percent of emergency department visits were made by people who reported having a usual source of health care other than an emergency department, 85 percent reported having medical insurance, and 79 percent reported having incomes exceeding the poverty threshold. Individuals without health insurance were no more likely to have had an emergency visit than those with private health insurance, and individuals without a usual source of care were 25 percent less likely to have had an emergency visit than those with a private physician.

“Contrary to popular perception, individuals who do not have a usual source of care are actually less likely to have visited an emergency department than those who have such care,” said the study’s lead author Ellen J. Weber, MD, Professor of Clinical Medicine in the division of emergency medicine at the University of California, San Francisco. “Many insurance programs, and particularly public and private HMOs, require beneficiaries to have a primary care physician, which may be expected to improve overall health and health care, but the continued rise in emergency visits implies that such programs have not had a substantial impact on overall emergency department use.”

“The mistaken belief that emergency departments are overcrowded by a small disenfranchised portion of the U.S. population can lead to misguided policy decisions and a perception by hospital administrators that emergency patients are not as valuable to the institution as patients having elective surgeries,” said Dr. Weber. “But our findings indicate that emergency departments serve as a safety net, not just for the poor and uninsured, but for mainstream Americans, and in particular those with serious and chronic illness.”

http://www.acep.org/1,34130,0.html

Comment: Clearly, the primary role of emergency departments is to serve as a safety net for mainstream Americans. Although much concern is expressed over the use of emergency departments by the disenfranchised poor and uninsured, this study confirms that emergency facilities are not being used as convenience clinics by this group. These people are simply not receiving the care that they need.

When the need for comprehensive reform is so obvious, we should not be distracted by efforts to enact misguided policies based on fundamental misperceptions.

Let’s first provide comprehensive coverage for everyone. Once health care funding is no longer the overriding issue, we can concentrate on policies that would ensure timely access to a usual source of care. Because of work conflicts and transportation issues, that might include enabling access to integrated convenience clinics. Whatever. But, at a current spending level of $1.8 trillion, we don’t need to increase funding; we need to start spending our funds more effectively.

Health care in America/Canada'S way

Thursday, October 14, 2004 (SF Chronicle)
In Critical Condition: Health Care In America/Canada’s Way/What a universal health care system delivers, good and bad
Barry Brown, Chronicle Foreign Service

Toronto — Discovering he had colon cancer came as a shock to John Kioussis, but after 10 days in the hospital, attended by a battery of medical specialists, technicians, nurses and other staff, his bill came to less than $85 in American dollars — and that was only for his phone and cable TV.

Under Canada’s government-funded health insurance system, Kioussis’ care, from the first visit to a family doctor, through visits to two specialists of his choice and his hospital stay, was free, paid for by Ontario’s publicly funded universal health coverage.

“When you’re sick like that and off work, the last thing you want to worry about is how to pay the bill,” said Kioussis, 55. “I had excellent care and one of the top specialists in the country, the same doctor who would treat the prime minister.”

That’s the side of Canadian health care familiar to many Americans — a system that provides free cradle-to-grave treatment to all, regardless of income or employment status.

The fact is, though, that Canada’s system is riddled with problems, many stemming from inadequate funding. As a result, delays of several months are common before seeing a specialist or getting nonemergency surgery.

For his part, Kioussis said the month he waited between seeing his family doctor and his surgery did not seem unreasonable. He admitted, though, that because of a personal connection between his brother and the surgeon, the doctor operated on him just before he left for vacation.

Although delays and other problems have caused support to dip slightly, Canadians still overwhelmingly back their universal health program. They think of their health care system as a mark of their national identity, something that separates them from Americans.

Meanwhile, a recent ABC News poll showed that while Americans value the quality of U.S. health care, 62 percent think the nation should shift to a universal health insurance program like Canada’s.

As a result of the sharply differing approaches Canada and the United States have taken toward financing health care, their medical systems have developed in contrasting ways.

The United States has more hospital beds per person than Canada because most American hospitals are private, while almost all Canadian hospitals are publicly funded. As a result, American hospitals compete for patients, while Canadian hospitals “don’t fund excess capacity,” said Sharon Sholzberg-Gray, chief executive of the Canadian Healthcare Association.

By many measures, Canadians are healthier than Americans, with a longer lifespan and lower infant mortality, even though they spend much less on medical care. Canadians devote about 10 percent of their gross domestic product, the total of a nation’s goods and services, to provide full health coverage for all citizens. American health costs account for about 14 percent of GDP, yet 45 million Americans have no health insurance and many more have limited coverage.

One of the main culprits pushing up the cost of care in the United States is the expense of administering a plethora of complicated health plans. It has been estimated that any large health insurer in a midsize U.S. state spends more on administration than is spent on health administration in all Canada.

Dr. Catherine Kurosu is a gynecologist at two San Diego hospitals. A Canadian, she said the biggest differences between the two systems are that poorer Americans won’t seek medical care until their problems have become serious. In addition, she said, American insurers often play games to avoid paying bills.

In San Diego, a lot of pregnant women — especially illegal immigrants — show up with problems that could have been avoided with prenatal care, she said. The idea that they can’t get this kind of care “still seems foreign to me,” she said.

My patients are always interested in finding out about the health care system when they find out I’m Canadian,” she continued.When it comes to billing, the Canadian system is a simple matter of sending an invoice to the Ministry of Health, which pays on a fee-for-service basis, she explained. In the United States, there are so many insurance companies, each with its own rules covering not only the patient but also the doctor — as Kurosu learned when she had to wait months for an insurance company to approve her.

U.S. health insurers nickel and dime doctors by always sending bills back and questioning everything, she said. “It’s like a game to see how long they can forestall payment.”

Eleven years ago, Colleen Burns started a medical imaging business in Buffalo, N.Y., right across the border from Ontario. She expected 20 percent of her business would come from Canadians willing to pay $300 to $600 in U.S. for quicker access to high-tech diagnostics. Instead, the proportion is only about 8 to 10 percent, she said. Canadians need to feel a sense of urgency and have the money before coming to the United States, “because they can get an MRI for free in Canada,” she said.

The health system is now itself in need of emergency care in order to continue offering the benefits Canadians have come to think of as their birthright, according to many experts. Dr.Albert Schumacher, president of the Canadian Medical Association, warns that shortfalls of cash and medical staff have left the system unsustainable without major reform.

Twenty years ago, Canada’s federal government unified the various health insurance programs run by the provinces.Ottawa offered to pay 50 percent of the programs’ operating budgets, provided the provincial plans accepted five basic principles, including nationwide acceptance of each provincial plan, comprehensive coverage and no out-of-pocket costs (co-payments or deductibles) for insured services.

“But since then, the federal share has dropped to as low as 14 percent,” said Schumacher, a family physician from the border city of Windsor, Ontario.

In the 1990s, Canadian governments at all levels began attacking their budget deficits with single-minded intensity. With health care accounting for about 40 percent of public sector spending, hospitals were closed, physician fees were frozen or cut, nurses were laid off, and spaces for medical students and medical technicians at government-funded universities and colleges were cut back.

Along with a money crunch, Canada “has a terrible shortage of physicians, “particularly specialists and surgeons, a high proportion of whom are over 55 and ready to retire, Schumacher said. Fixing the health care system has become a high priority for Canada’s political leaders.

Last month, Prime Minister Paul Martin made good on his main election promise to inject more cash into provincial health programs and move to shorten waiting lists.

At a national health care summit, Martin told provincial leaders Ottawa would ante up the equivalent of an additional $34 billion in U.S. funds over 10 years to provincial and territorial health programs, as well as an additional $3 billion to ease wait times for hip replacement surgeries, cardiac and cancer treatments. He also agreed to a plan for monitoring waiting lists to determine the best method of reducing them.

As in the United States, the main problems bedeviling Canada are the soaring cost of prescription drugs and an aging population. Canada’s provinces had called on Ottawa to use its hefty budgetary surplus to launch a national drug plan and leave to them the remaining health care costs, including home care and services like psychiatry and chiropractics.But during the summit, provincial leaders abandoned that effort in exchange for more overall funding from Ottawa.

Sholzberg-Gray of the Canadian Healthcare Association said another challenge plaguing the Canadian system is the drain of doctors and nurses lured by higher pay and lower taxes in the United States.

“There is also a circular effect, because some doctors come back so they don’t have to collect bills,” she added. On the issue of waiting lists for nonemergency surgery, Sholzberg-Gray believes the federal government should establish time limits for treatment.

One feature of Canada’s health care system is that if someone wants to bypass the public program and, for example, pay a doctor to perform hip replacement surgery after hours, he cannot. Because of fears that slipping the doctor a little something extra could lead to the breakdown of the equal- access-for-all principle, paying for insured services is illegal.Those who believe that more private care clinics would solve the problem of funding and shortages have taken their case to Canada’s Supreme Court in an effort to open the system.

ODD MAN OUT
The United States is the only developed nation without universal health care. Although health insurance systems worldwide are straining as populations age, safety nets have largely remained in place. Here are brief descriptions of insurance systems of several nations..

France
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory health insurance provided by
Social Security, with private supplemental coverage filling gaps..
Germany
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved health insurance plans partly financed by employer and employee contributions, although high-income workers may buy private insurance instead..
Japan
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll in insurance programs through their jobs, while all others join Japan’s national health insurance plan..
United Kingdom
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service provides free care, with the option of private insurance for those wanting treatment outside the state system..
United States
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most of the cost of care for seniors and
the poor, with employer or individually financed insurance available for others. About 45 million people lack coverage.
*2001 figures
Source: World Health Organization, Chronicle research

Five-Part Series
This week The Chronicle is examining in depth the causes, effects and responses to rising health care costs in America.
Monday
Why health care costs are rising fast. Plus the Bush and Kerry health care plans.
Tuesday
Retirees hit hard as health benefits are lost.
Wednesday
Health care tops the labor-management agenda.
Today
How Canada provides health care for all.
Friday
Employees are digging deeper to pay for health insurance.

Health care in America/Canada’S way

Thursday, October 14, 2004 (SF Chronicle)
In Critical Condition: Health Care In America/Canada’s Way/What a universal health care system delivers, good and bad
Barry Brown, Chronicle Foreign Service

Toronto — Discovering he had colon cancer came as a shock to John Kioussis, but after 10 days in the hospital, attended by a battery of medical specialists, technicians, nurses and other staff, his bill came to less than $85 in American dollars — and that was only for his phone and cable TV.

Under Canada’s government-funded health insurance system, Kioussis’ care, from the first visit to a family doctor, through visits to two specialists of his choice and his hospital stay, was free, paid for by Ontario’s publicly funded universal health coverage.

“When you’re sick like that and off work, the last thing you want to worry about is how to pay the bill,” said Kioussis, 55. “I had excellent care and one of the top specialists in the country, the same doctor who would treat the prime minister.”

That’s the side of Canadian health care familiar to many Americans — a system that provides free cradle-to-grave treatment to all, regardless of income or employment status.

The fact is, though, that Canada’s system is riddled with problems, many stemming from inadequate funding. As a result, delays of several months are common before seeing a specialist or getting nonemergency surgery.

For his part, Kioussis said the month he waited between seeing his family doctor and his surgery did not seem unreasonable. He admitted, though, that because of a personal connection between his brother and the surgeon, the doctor operated on him just before he left for vacation.

Although delays and other problems have caused support to dip slightly, Canadians still overwhelmingly back their universal health program. They think of their health care system as a mark of their national identity, something that separates them from Americans.

Meanwhile, a recent ABC News poll showed that while Americans value the quality of U.S. health care, 62 percent think the nation should shift to a universal health insurance program like Canada’s.

As a result of the sharply differing approaches Canada and the United States have taken toward financing health care, their medical systems have developed in contrasting ways.

The United States has more hospital beds per person than Canada because most American hospitals are private, while almost all Canadian hospitals are publicly funded. As a result, American hospitals compete for patients, while Canadian hospitals “don’t fund excess capacity,” said Sharon Sholzberg-Gray, chief executive of the Canadian Healthcare Association.

By many measures, Canadians are healthier than Americans, with a longer lifespan and lower infant mortality, even though they spend much less on medical care. Canadians devote about 10 percent of their gross domestic product, the total of a nation’s goods and services, to provide full health coverage for all citizens. American health costs account for about 14 percent of GDP, yet 45 million Americans have no health insurance and many more have limited coverage.

One of the main culprits pushing up the cost of care in the United States is the expense of administering a plethora of complicated health plans. It has been estimated that any large health insurer in a midsize U.S. state spends more on administration than is spent on health administration in all Canada.

Dr. Catherine Kurosu is a gynecologist at two San Diego hospitals. A Canadian, she said the biggest differences between the two systems are that poorer Americans won’t seek medical care until their problems have become serious. In addition, she said, American insurers often play games to avoid paying bills.

In San Diego, a lot of pregnant women — especially illegal immigrants — show up with problems that could have been avoided with prenatal care, she said. The idea that they can’t get this kind of care “still seems foreign to me,” she said.

My patients are always interested in finding out about the health care system when they find out I’m Canadian,” she continued.When it comes to billing, the Canadian system is a simple matter of sending an invoice to the Ministry of Health, which pays on a fee-for-service basis, she explained. In the United States, there are so many insurance companies, each with its own rules covering not only the patient but also the doctor — as Kurosu learned when she had to wait months for an insurance company to approve her.

U.S. health insurers nickel and dime doctors by always sending bills back and questioning everything, she said. “It’s like a game to see how long they can forestall payment.”

Eleven years ago, Colleen Burns started a medical imaging business in Buffalo, N.Y., right across the border from Ontario. She expected 20 percent of her business would come from Canadians willing to pay $300 to $600 in U.S. for quicker access to high-tech diagnostics. Instead, the proportion is only about 8 to 10 percent, she said. Canadians need to feel a sense of urgency and have the money before coming to the United States, “because they can get an MRI for free in Canada,” she said.

The health system is now itself in need of emergency care in order to continue offering the benefits Canadians have come to think of as their birthright, according to many experts. Dr.Albert Schumacher, president of the Canadian Medical Association, warns that shortfalls of cash and medical staff have left the system unsustainable without major reform.

Twenty years ago, Canada’s federal government unified the various health insurance programs run by the provinces.Ottawa offered to pay 50 percent of the programs’ operating budgets, provided the provincial plans accepted five basic principles, including nationwide acceptance of each provincial plan, comprehensive coverage and no out-of-pocket costs (co-payments or deductibles) for insured services.

“But since then, the federal share has dropped to as low as 14 percent,” said Schumacher, a family physician from the border city of Windsor, Ontario.

In the 1990s, Canadian governments at all levels began attacking their budget deficits with single-minded intensity. With health care accounting for about 40 percent of public sector spending, hospitals were closed, physician fees were frozen or cut, nurses were laid off, and spaces for medical students and medical technicians at government-funded universities and colleges were cut back.

Along with a money crunch, Canada “has a terrible shortage of physicians, “particularly specialists and surgeons, a high proportion of whom are over 55 and ready to retire, Schumacher said. Fixing the health care system has become a high priority for Canada’s political leaders.

Last month, Prime Minister Paul Martin made good on his main election promise to inject more cash into provincial health programs and move to shorten waiting lists.

At a national health care summit, Martin told provincial leaders Ottawa would ante up the equivalent of an additional $34 billion in U.S. funds over 10 years to provincial and territorial health programs, as well as an additional $3 billion to ease wait times for hip replacement surgeries, cardiac and cancer treatments. He also agreed to a plan for monitoring waiting lists to determine the best method of reducing them.

As in the United States, the main problems bedeviling Canada are the soaring cost of prescription drugs and an aging population. Canada’s provinces had called on Ottawa to use its hefty budgetary surplus to launch a national drug plan and leave to them the remaining health care costs, including home care and services like psychiatry and chiropractics.But during the summit, provincial leaders abandoned that effort in exchange for more overall funding from Ottawa.

Sholzberg-Gray of the Canadian Healthcare Association said another challenge plaguing the Canadian system is the drain of doctors and nurses lured by higher pay and lower taxes in the United States.

“There is also a circular effect, because some doctors come back so they don’t have to collect bills,” she added. On the issue of waiting lists for nonemergency surgery, Sholzberg-Gray believes the federal government should establish time limits for treatment.

One feature of Canada’s health care system is that if someone wants to bypass the public program and, for example, pay a doctor to perform hip replacement surgery after hours, he cannot. Because of fears that slipping the doctor a little something extra could lead to the breakdown of the equal- access-for-all principle, paying for insured services is illegal.Those who believe that more private care clinics would solve the problem of funding and shortages have taken their case to Canada’s Supreme Court in an effort to open the system.

ODD MAN OUT
The United States is the only developed nation without universal health care. Although health insurance systems worldwide are straining as populations age, safety nets have largely remained in place. Here are brief descriptions of insurance systems of several nations..

France
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory health insurance provided by
Social Security, with private supplemental coverage filling gaps..
Germany
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved health insurance plans partly financed by employer and employee contributions, although high-income workers may buy private insurance instead..
Japan
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll in insurance programs through their jobs, while all others join Japan’s national health insurance plan..
United Kingdom
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service provides free care, with the option of private insurance for those wanting treatment outside the state system..
United States
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most of the cost of care for seniors and
the poor, with employer or individually financed insurance available for others. About 45 million people lack coverage.
*2001 figures
Source: World Health Organization, Chronicle research

Five-Part Series
This week The Chronicle is examining in depth the causes, effects and responses to rising health care costs in America.
Monday
Why health care costs are rising fast. Plus the Bush and Kerry health care plans.
Tuesday
Retirees hit hard as health benefits are lost.
Wednesday
Health care tops the labor-management agenda.
Today
How Canada provides health care for all.
Friday
Employees are digging deeper to pay for health insurance.

AMSA’s Casey Kirkhart on Liability Reform

Yesterday’s message on physicians’ ranking of liability reform as their number one issue provoked numerous responses. The predominant theme of the replies was that the dramatic increases in liability insurance premiums cannot be absorbed by fee increases since most fees are now controlled by public and private third party payers. It is clear that the current debate limited to MICRA-type reforms is missing the point. We need dramatic new approaches to the problem of medical injury.

Following is a much more inspiring message from a voice representing the future of health care in America.

Casey KirkHart, DO, Jack Rutledge Fellow of the American Medical Student Association (AMSA):

Thank you for this post and for your insightful comments.

I too have experienced a mix of reactions to the swelling of physician (and medical student) involvement in the political process vis a vis medical liability. As an organizer of future physicians, I relish the idea of students and physicians standing up together in the public eye to call for change to our dire health care system. Health professionals, in particular young doctors and students, must lead the call to reform as AMSA and others have done for decades.

On the other hand, I can’t think of a more fruitless and uninspiring political battle than the one surrounding tort reform. I spent the last few weeks touring medical schools in various swing states discussing the candidates’ health plans. The debate would invariably turn to medical liability, despite potential real ground to be made this November 2nd on health care access and affordability. While an important issue to address, I feel that it is more political “smoke and mirrors” in comparison to the bevy of ailments facing medical practice and the health care system.

In my leadership capacity, I have been asked to speak to and support efforts around tort reform, and when I do, I do so with caution. I suggest to medical students to examine every side of the medical malpractice issue, from the patient, lawyer, physician, and systemic perspectives, before investing oneself in the tort battle. Until we create a more comprehensive solution to malpractice, including those proposed by Kerry and Edwards, I fear little relief from the so-called medical malpractice crisis.

Some physicians’ organizations have made this their #1 legislative issue, but medical students have, quite possibly, the only comprehensive answers. In the last few years, AMSA has passed policy that describes our priorities in medical malpractice and I am proud to say that they are founded first and foremost in patient safety, physician security and excellence, and honoring the clinical relationship.

I invite you to read AMSA’s stance on medical malpractice at http://www.amsa.org/about/ppp/prof.pdf#zoom=120,40,50

We have produced a number of sophisticated educational pieces on medical malpractice and the forces that shape it. Please feel free to share this resource with your colleagues and students. I would appreciate feedback on this useful tool.

http://www.amsa.org/hp/issues.cfm

I hope you found these comments, well, hopeful. I can attest that in the hearts and minds of future physicians, our priorities differ greatly from those of the survey. The future of medicine is in good, strong hands.

In solidarity,
Casey KirkHart, DO
AMSA Jack Rutledge Fellow

Don’s comment: For those interested in this topic, I emphatically recommend the links noted in Casey’s message.

AMSA's Casey Kirkhart on Liability Reform

Yesterday’s message on physicians’ ranking of liability reform as their number one issue provoked numerous responses. The predominant theme of the replies was that the dramatic increases in liability insurance premiums cannot be absorbed by fee increases since most fees are now controlled by public and private third party payers. It is clear that the current debate limited to MICRA-type reforms is missing the point. We need dramatic new approaches to the problem of medical injury.

Following is a much more inspiring message from a voice representing the future of health care in America.

Casey KirkHart, DO, Jack Rutledge Fellow of the American Medical Student Association (AMSA):

Thank you for this post and for your insightful comments.

I too have experienced a mix of reactions to the swelling of physician (and medical student) involvement in the political process vis a vis medical liability. As an organizer of future physicians, I relish the idea of students and physicians standing up together in the public eye to call for change to our dire health care system. Health professionals, in particular young doctors and students, must lead the call to reform as AMSA and others have done for decades.

On the other hand, I can’t think of a more fruitless and uninspiring political battle than the one surrounding tort reform. I spent the last few weeks touring medical schools in various swing states discussing the candidates’ health plans. The debate would invariably turn to medical liability, despite potential real ground to be made this November 2nd on health care access and affordability. While an important issue to address, I feel that it is more political “smoke and mirrors” in comparison to the bevy of ailments facing medical practice and the health care system.

In my leadership capacity, I have been asked to speak to and support efforts around tort reform, and when I do, I do so with caution. I suggest to medical students to examine every side of the medical malpractice issue, from the patient, lawyer, physician, and systemic perspectives, before investing oneself in the tort battle. Until we create a more comprehensive solution to malpractice, including those proposed by Kerry and Edwards, I fear little relief from the so-called medical malpractice crisis.

Some physicians’ organizations have made this their #1 legislative issue, but medical students have, quite possibly, the only comprehensive answers. In the last few years, AMSA has passed policy that describes our priorities in medical malpractice and I am proud to say that they are founded first and foremost in patient safety, physician security and excellence, and honoring the clinical relationship.

I invite you to read AMSA’s stance on medical malpractice at http://www.amsa.org/about/ppp/prof.pdf#zoom=120,40,50

We have produced a number of sophisticated educational pieces on medical malpractice and the forces that shape it. Please feel free to share this resource with your colleagues and students. I would appreciate feedback on this useful tool.

http://www.amsa.org/hp/issues.cfm

I hope you found these comments, well, hopeful. I can attest that in the hearts and minds of future physicians, our priorities differ greatly from those of the survey. The future of medicine is in good, strong hands.

In solidarity,
Casey KirkHart, DO
AMSA Jack Rutledge Fellow

Don’s comment: For those interested in this topic, I emphatically recommend the links noted in Casey’s message.

#1 Issue for Physicians

Political passions drive doctors to campaign
By Joel B. Finkelstein
American Medical News – Oct. 25, 2004

Issues important to physicians
In a survey of 1,050 physicians…
Ranked as No. 1 issue:

42% – Liability reform
20% – Cost of coverage
18% – Uninsured Americans
10% – Abortion
04% – Medicare
03% – Patients’ rights
02% – Cost of Rx drugs
01% – Benefits for seniors

Source: Muhlenberg College

http://www.ama-assn.org/amednews/2004/10/25/gvl21025.htm

Comment: My first reaction was the profound sense of sorrow felt on my realization that physicians do not place the plight of the uninsured and lack of affordability of health care above all else. The actual impact of liability issues on the health care system is almost negligible when contrasted with the major impact of financial hardship, suffering and even loss of life that insurance and cost issues have. How could physicians ever come to the conclusion that the nuisance of facing lawsuits is a more important issue than the suffering and financial hardship of many of their patients?

But giving this more thought, instead of going into a funk over how physicians could be so callous, I decided that we need to ask ourselves why so many physicians do place this as the number one priority. It is unlikely that individuals who have dedicated their lives to the healing arts are really insensitive to their patients’ needs. It is more likely that physicians are exposed to unrelenting anxiety and stress that has made their lives relatively miserable. Although, objectively, that level of misery cannot compare to the suffering of their patients who cannot afford access to care, it must be foremost in their minds, probably because it is a psychological pain that never seems to go away.

There is a lesson here. We want our health care professionals to be contented as they dedicate themselves to improving the health of their patients. Malcontented professionals will always underperform.

Medical injury is certainly an issue that we must address. But it is very clear that the process must be revolutionized so that the physicians’ motivations will be to assist their patients in attaining access to care in an environment that is as error-free as possible, but also to assist them in obtaining appropriate compensation when the system has failed to prevent harmful errors.

The patient must always be placed first. And the patients’ interests will be served best in an environment that is a rewarding experience for the patients’ health care professionals.

1.7 Million Veterans Lacked Health Coverage In 2003

Contact:
Laura Finlayson, laura@rosica.com
or Tiffanie McKinnon, tiffanie@rosica.com,(201) 843-5600
Nick Skala, nick@pnhp.org, (312) 782-6006

Embargoed Until Tuesday, October 19, 2004 – 12:00 PM

1.7 MILLION VETERANS LACKED HEALTH COVERAGE IN 2003

Harvard/Public Citizen Study Finds Sharp Increase Since 2000

1.694 million American veterans were uninsured in 2003, according to a study by Harvard Medical School researchers released today. Of the 1.694 million uninsured, 681,808 were Vietnam-era veterans while 999,548 were veterans who served during other eras (including the Persian Gulf War).

The study was based on analyses of government surveys. Veterans were only classified as uninsured if they neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics. Many of the 1.694 million uninsured veterans in 2003 were barred from VHA care because of a 2003 Bush Administration order that halted enrollment of most middle income veterans. Others were unable to obtain VHA care due to waiting lists at some VHA facilities, unaffordable co-payments for VHA specialty care, or the lack of VHA facilities in their communities. An additional 3.90 million members of veterans’ households were also uninsured and ineligible for VHA care. Other findings of the study include:

*The number of uninsured veterans has increased by 235,159 since 2000, when 9.9% of non-elderly veterans were uninsured, a figure which rose to 11.9% in 2003.

*More than one in three veterans under age 25 lacked health coverage, as did one in seven veterans age 25 to 44 and one in ten veterans age 45 to 65.

*Many uninsured veterans had major health problems. Less than one-quarter indicated that they were in excellent health; 15.6% had a disabling chronic illness.

*Uninsured veterans had as much trouble getting medical care as other uninsured persons. 26.1% of uninsured veterans reported that they had failed to get needed care due to costs; 29.0% had delayed care due to costs; 42.1% had not seen a doctor within the past year; and two-thirds failed to receive preventive care
more
1.7 Million Veterans Lacked Health Coverage in 2003 — add one

*More than two-thirds of uninsured veterans were employed and 86.4% had worked within the past year; 7% of the uninsured vets worked at two or more jobs.

David U. Himmelstein, M.D., study author and Harvard Medical School Associate Professor, commented: “This administration professes great concern for veterans, but it’s all talk and no action. Since President Bush took office the number of uninsured vets has skyrocketed, and he’s cut VA eligibility, barring hundreds of thousands of veterans from care. Our president has put troops in harm’s way overseas and abandons them and their families once they get home.

“Like other uninsured Americans, most uninsured vets are working people. And uninsured veterans are denied the care they need ” turned away because they can’t pay,” said Dr. Steffie Woolhandler, a study author and co-founder of Physicians for a National Health Program. “We need a solution that works for veterans, and for all Americans — national health insurance.”

Sidney M. Wolfe, M.D., study author and Director of Public Citizen’s Health Research Group said, “The armed services are aggressive in encouraging people to join the military to serve their country and to (be all you can be). But after leaving the service, almost 1.7 million veterans do not have the right to health care, in a way, being discarded by the government after serving their country. Without access to health care, no one can be all that they can be.”

Physicians for a National Health Program is a national organization with more than 12,000 physician members that advocates for national health. Public Citizen is a national non-profit organization with 150,000 members that engages in research and advocacy to protect health, safety and democracy.
###
To download the Veterans report (pdf)
Please click here

San Francisco Chronicle Series: Monopsony is the Answer

Monopsony: A market situation in which the product or service of several
sellers is sought by only one buyer.
The American Heritage Dictionary of the English Language
http://www.bartleby.com/61/83/M0398300.html

The San Francisco Chronicle – October 11-15, 2004
IN CRITICAL CONDITION: HEALTH CARE IN AMERICA

This week, the San Francisco Chronicle has published an excellent series of articles on our health care system:

Why health care costs are rising fast. Plus the Bush and Kerry health care plans.
http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2004/10/11/MNGII96CVP1.DTL
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2004/10/11/MNGII96D031.DTL

Retirees hit hard as health benefits are lost.
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2004/10/12/BUGMN979TS1.DTL

Health care tops the labor-management agenda.
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2004/10/13/BUGMN97GRD1.DTL

How Canada provides health care for all.
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2004/10/14/BUGR28JFEN59.DTL

Employees are digging deeper to pay for health insurance.
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2004/10/15/BUG7T8E81H63.DTL

Don Bechler, Health Care for All – San Francisco, is compiling some talking points in response to this series, especially the article on the Canadian model.

This is my contribution:

Point:
There are major fundamental flaws in our health care system that cannot possibly be corrected by addressing each as an isolated problem. Comprehensive reform will be possible only by forming our own, universal, monopsonistic purchasing system, a single payer system.

Explanation:
Flaws include such factors as an irrational overpricing of certain services and products (e.g., pharmaceuticals), the excessive and expensive administrative burden placed on health care providers, the failure to provide greater incentives for a higher quality, lower cost primary care infrastructure, and the wasteful and detrimental excesses of high tech care in a system characterized by regional and selective excess capacities.

The last point is not receiving enough attention but is extremely important. It is timely now because Health Affairs has released a series of twenty articles on the topic. They can be downloaded for free, but only until October 21! After that time you will need to be a subscriber or will have to purchase each individual article to access them on the Internet.

The Health Affairs articles are listed under “7 October 2004” at:
http://content.healthaffairs.org/webexclusives/index.dtl?year=2004

We cannot possibly control costs and improve quality unless we harness the power of monopsonistic purchasing. And that just happens to have the added advantage of ensuring affordable, comprehensive coverage for everyone.

Don McCanne

Healthcare Debate on "Democracy Now"

AMY GOODMAN: We’re joined by Dr. Steffie Woolhandler, association professor of Medicine at Harvard University, co-director of the Harvard Medical School General Internal Medicine Fellowship program. Also, Sally Pipes, president of the San Francisco based Pacific Research Institute, author of the new book, Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer. Sally Pipes, let’s begin with you. You’re assessment of what President Bush has proposed as well as John Kerry?

SALLY PIPES: Yes. Good morning, Amy. I grew up in Canada under Canadian health care, and now the average wait in Canada from seeing a GP to a specialist has gone from in 1993 from nine weeks to 17.9 weeks. So, we have two different plans here. President Bush’s plan is talking about, you know, giving patients and doctors control over the health care rather than government bureaucrats. He’s looking at expanding health savings accounts to provide affordable coverage to individuals and businesses. He’s talking about making changes in tort reform to reduce malpractice awards. He is setting up association health plans so small businesses can band together and provide coverage for workers. Plus refundable tax credits for low income American individuals and families. On the other hand, presidential candidate, Kerry, his plan in my estimate and those of others, economists that I work with, is trillion dollars over ten years. He is saying that he will get this money through rescinding the Bush tax cuts. That would really only cover one-third of the cost. But the real issue in the Kerry plan is he would move the American people more to a Canadian single payer style system. This is just one step. It’s really talking about putting millions of middle income Americans into Medicaid, the federal state health plan for the poor, and putting millions of more Americans into a system of managed competition, which is similar to what Hillary Clinton proposed more than a decade ago. I’ll just make one point on that and you know, when you look at President Clinton and his terrible heart problem, he went in to the doctor on a Thursday, and he had an angiogram Friday, on Monday, he had quadruple bypass. If he lived in Canada, or if Hillary Clinton’s plan had passed, he would be looking at an average wait of 3.4 weeks from seeing a GP to seeing a cardiologist, another 2.1 weeks for having urgent bypass. If it wasn’t that urgent, it would be 10.7 weeks. His plan really is putting more and more government into our lives. The Bush plan is really talking about letting consumers be empowered to take control over their health care and I think that in my opinion, having grown up under Canadian health care, this is the option that Americans will like. You cannot take the American people into that program. It’s just a government program. It’s just not going to work.

JUAN GONZALEZ: Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard University, your response to the Bush plan and also your sense of what Senator Kerry’s plan entails.

DR. STEFFIE WOOLHANDLER: I’ll get to Bush and Kerry in a minute, but I cannot let the falsehoods about Canada stand. When people look scientifically at waits in Canada the average wait for urgent heart surgery is one day. The average wait for non-urgent heart surgery is 17 days. So, Sally’s numbers come from a crackpot research organization that has no credibility, and her organization has been spreading those numbers around and they’re not true. The truth is Canadians have complete free choice of doctor or hospital. They live
two to three years longer than Americans, and they’re spending about half of what we do on health care. The reason is that they have so much administrative efficiency by getting rid of the insurance companies and their paperwork, they can afford universal care. Now, our group, Physicians for a National Health Program, which is a leading advocate of single payer health care, does not advocate the Canadian system. We advocate Canada Deluxe. We advocate spending the same amount what they’re spending now twice what they have in Canada, but achieve the administrative efficiency and universal coverage of Canada, so we could cover everyone with no waits of any type. But getting back to the question of Bush and Kerry, Mr. Kerry gets us less than halfway there, even if his plan is successful. He will leave 17 million Americans with no health insurance. Let’s not pretend that’s really universal health care.

Mr. Bush’s plan is actually quite a bit worse. He intends to pour money into tax credits which will not succeed in covering people. We know that because Mr. Bush is modeling his plan after an existing tax credit program called the Trade Adjustment Assistance Act, where less than 2% of eligible people have decided to take the tax credit. The reason is that Bush is talking about offering a tax credit of $3,000 for a family to buy health insurance. But the average family policy in this country costs $10,000. This would leave a family with $7,000 they would have to take out of their own pocket in order to get health insurance. And obviously, a low income family, an unemployed family, is not in a position to pay an additional $7,000 out of their pocket for health care. Hence the tax credits are not going to be sufficient to allow low income people to buy health insurance and they’re simply not going to get any coverage out of Mr. Bush.

JUAN GONZALEZ: Sally Pipes, your response, especially on the whole issue of the administrative cost savings as a result of the plans of Senator Kerry; and doesn’t a bigger, more organized system with one buyer have power to control prices better and to prevent health care costs from spiraling?

SALLY PIPES: The Canadian system is expensive. First of all, you’re comparing apples with oranges. Canada doesn’t include the capital costs of hospitals in their numbers.

DR. STEFFIE WOOLHANDLER: That isn’t true.

SALLY PIPES: Excuse me. Canada has the third most expensive health care system in the world after the United States and Switzerland. Canadians, if you look on websites, you will see the stories of Canadians who are having to wait, who cannot get doctors and are leaving Canada to come to the United States. There’s a woman in Quebec, who is suing the Quebec government in a malpractice suit for $37 million. She’s suing on behalf of 10,000 Quebec breast cancer patients who had to wait over the limit of eight weeks to get radiation oncology. The Canadian Medical Association came out with a report two weeks ago saying that over 50% of Canadians are incredibly dissatisfied with the health care that they are getting, just look on websites and see the number of Canadians who are upset. And Canadians use America as a safety valve. Look at the border towns. Senator Ed Lawson, who was head of the Teamsters union, and became national senator, when he was diagnosed two years ago with heart situations similar to president Clintons, they told him to wait, even a person of such importance as himself, left and came to — went to Seattle, Washington, because he didn’t want to wait two weeks to get an angiogram. So,you know, I’m not a crackpot institute. That was very insulting. I have done a lot of work. I have worked in Canada on this issue. There is tremendous work done by the Frasier Institute in Canada on hospital waiting lists. It’s all scientifically done. The administrative costs in Canada, you’re not comparing apples with apples it is the third most expensive system in the world.

In the United States today, 45% of our health care dollars are actually in the government system between Medicaid, Medicare, the State Children’s Health Insurance Program and things like that.

DR. STEFFIE WOOLHANDLER: I’m not calling Sally a crackpot. I’m calling Frasier Institute that she quotes extensively crackpot. This is the group that thinks we ought to privatize the whales. This is a group that thinks that we should abolish medical licenses.

SALLY PIPES: This is a group that thinks there should be private options in Canada. I think a lot of people in the United States think that Canada

DR. STEFFIE WOOLHANDLER: Sally, I let you talk, okay. Now it’s my turn. The reality is Canada spends half of what we do. I happen to have published a definitive article on the administrative costs in the New England Journal of Medicine. I know what the Canadian hospital cost reports look like. I know what Canadian cost reports look like. Canada spends half of what we do. That’s what the Organisation for Economic Co-operation and Development and the UN say. And that’s the reason why they do have some waits for elective services in Canada. Elective services. Do think that’s a good thing? No. I don’t think we should have to wait for things. But if we have a Canadian style system, and spend twice as much money, then there’s no reason to have any waits. That’s not just my opinion, that’s also the opinion of the US General Accounting Office and the US Congressional Budget Office.

AMY GOODMAN: I’d like to ask Sally Pipes, what do you think is good about John Kerry’s proposal?

SALLY PIPES: Well, I don’t think that there are good things about it. I think the numbers came out from the Census Bureau saying that 45 million America ns do not have insurance. You have to look and analyze who are the 45 million Americans. Because 16% of them are people who are earning over $75,000. 33% are people who are earning over $50,000. Just because you don’t have health insurance does not mean that you don’t get health care. There’s a lot of money spent by individuals who don’t have health insurance who go out and buy their own. They pay out of pocket for their health care. Really, 8 million Americans are people who are chronically uninsured, and low income. Those are the people that I think that the government needs to take care of. And I definitely believe that there are — you know, children and low income families that do need care. I think for the rest of people, we need to open up system to empower consumers to get the best health care they can. People, when you look at any government program, most people do not like the DMV. The post office became more competitive when it opened up to competition from fed ex and UPS and a variety of things. Competition is what makes the world go around. Canadians do not have any form of competition. Any private coverage in Canada is outlawed under the Canada Health Act.

JUAN GONZALEZ: Let me ask you, Sally Pipes, drugs, the cost of prescription drugs have become a huge part of health care costs in this country, and if our system, as it is now structured, is doing so well, why are so many Americans trying to get to Canada, or to Mexico to buy prescription drugs?

SALLY PIPES: Today in America, Americans spend 1% of their income on prescription drugs. In the 1960’s Americans spent 1% of their income on prescription drugs. There are a number of drugs that are available in Canada– in the United States that allow us to — many — the drugs today allow us to live longer and healthier lives. From 1997 to 1999, out of 100 new drugs that became available in the United States, only 43 of them made it onto the formular
y in Canada. A lot of the top drugs in the United States that are used in Canada are generically available in the United States, and are cheaper, but the real issue here about prescription drugs, Americans want lower prices for prescription drugs. The reason they’re — the drugs are lower in Europe and Canada is because of price controls. So, what people really want in America is price controls on drugs, which is going to have a negative impact on research and development in this country, and innovation. New drugs have reduced costs for hospital stays because people can use drugs now for ulcers, for instead of having gall bladder surgery. We’re reducing costs by allowing Americans to have access to the greatest drugs and innovation in the world.

JUAN GONZALEZ: Dr. Steffie Woolhandler, I’d like you to respond to the issue of drugs and the differences between Canada and the United States.

DR. STEFFIE WOOLHANDLER: I want to remind that you, Canadians do live two to three years longer than Americans. That was not true before they went with National Health Insurance. That’s because the National Health Insurance program has allowed them good access to all types of care, including drugs. Canadians, about half of Canadians do get their drugs through their insurance. But all Canadians benefit from a system whereby the government negotiates with drug companies for lower prices. So, Canadians are paying about 60 cents on the dollar that Americans pay, and they’re paying only 60% of what we pay for drugs, and they really are the same drugs. Sally’s idea that you cannot get drugs in Canada is simply not true.

SALLY PIPES: I’m not saying you can’t get drugs.

DR. STEFFIE WOOLHANDLER: They have access to the same drugs that we do, they can just afford them. And similarly, Sally’s contention that uninsured people get all of the health care they need, doesn’t make common sense, but is also belied by a huge body of literature. Most recently, Ayanian colleagues published a study looking at people aged 55 to 65 who have no health insurance, and 10% of the people died over an eight-year period. They died at 33% higher rate than people who had insurance. It’s just common sense that if you don’t have a way to pay for care, you are going to get less of it, and it’s going to impact your health and maybe make your die younger.

AMY GOODMAN: Who benefits under Bush’s plan?

DR. STEFFIE WOOLHANDLER: Well, there’s a big benefit to some middle income taxpayers who end up taking a tax credit where they already had insurance. Now, they can get a tax credit that helps them pay for it. So, there’s some benefit to that. He’s very big, in general, Bush’s policies are very big with the insurance industry and drug industries. Because he has a very hands-off approach, where all of the government taxpayers do is just send more money into the system. There’s no attempt by the government to regulate things or make them more fair.

AMY GOODMAN: Sally pipes?

SALLY PIPES: Well, I’d like it just comment on one thing. Canada is a country of 32 million people, fewer than in the state of California. We have much less ethnically diverse. We don’t have the minority low income populations that are in the United States. If you compare white Canadians to white Americ ans, Americans are now living longer than Canadians. I think that the Bush plan

DR. STEFFIE WOOLHANDLER: No, that isn’t true, Sally. It’s simply not true. Canada Health Survey .

AMY GOODMAN: We actually have to leave it there. I want to thank you both for being with us. I know that you both have to race off anyway. Sally Pipes, president of the San Francisco based Pacific Research Institute. Her new book is called Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer. Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard University, and co-founder of Physicians for a National Health Program.

Healthcare Debate on “Democracy Now”

AMY GOODMAN: We’re joined by Dr. Steffie Woolhandler, association professor of Medicine at Harvard University, co-director of the Harvard Medical School General Internal Medicine Fellowship program. Also, Sally Pipes, president of the San Francisco based Pacific Research Institute, author of the new book, Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer. Sally Pipes, let’s begin with you. You’re assessment of what President Bush has proposed as well as John Kerry?

SALLY PIPES: Yes. Good morning, Amy. I grew up in Canada under Canadian health care, and now the average wait in Canada from seeing a GP to a specialist has gone from in 1993 from nine weeks to 17.9 weeks. So, we have two different plans here. President Bush’s plan is talking about, you know, giving patients and doctors control over the health care rather than government bureaucrats. He’s looking at expanding health savings accounts to provide affordable coverage to individuals and businesses. He’s talking about making changes in tort reform to reduce malpractice awards. He is setting up association health plans so small businesses can band together and provide coverage for workers. Plus refundable tax credits for low income American individuals and families. On the other hand, presidential candidate, Kerry, his plan in my estimate and those of others, economists that I work with, is trillion dollars over ten years. He is saying that he will get this money through rescinding the Bush tax cuts. That would really only cover one-third of the cost. But the real issue in the Kerry plan is he would move the American people more to a Canadian single payer style system. This is just one step. It’s really talking about putting millions of middle income Americans into Medicaid, the federal state health plan for the poor, and putting millions of more Americans into a system of managed competition, which is similar to what Hillary Clinton proposed more than a decade ago. I’ll just make one point on that and you know, when you look at President Clinton and his terrible heart problem, he went in to the doctor on a Thursday, and he had an angiogram Friday, on Monday, he had quadruple bypass. If he lived in Canada, or if Hillary Clinton’s plan had passed, he would be looking at an average wait of 3.4 weeks from seeing a GP to seeing a cardiologist, another 2.1 weeks for having urgent bypass. If it wasn’t that urgent, it would be 10.7 weeks. His plan really is putting more and more government into our lives. The Bush plan is really talking about letting consumers be empowered to take control over their health care and I think that in my opinion, having grown up under Canadian health care, this is the option that Americans will like. You cannot take the American people into that program. It’s just a government program. It’s just not going to work.

JUAN GONZALEZ: Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard University, your response to the Bush plan and also your sense of what Senator Kerry’s plan entails.

DR. STEFFIE WOOLHANDLER: I’ll get to Bush and Kerry in a minute, but I cannot let the falsehoods about Canada stand. When people look scientifically at waits in Canada the average wait for urgent heart surgery is one day. The average wait for non-urgent heart surgery is 17 days. So, Sally’s numbers come from a crackpot research organization that has no credibility, and her organization has been spreading those numbers around and they’re not true. The truth is Canadians have complete free choice of doctor or hospital. They live
two to three years longer than Americans, and they’re spending about half of what we do on health care. The reason is that they have so much administrative efficiency by getting rid of the insurance companies and their paperwork, they can afford universal care. Now, our group, Physicians for a National Health Program, which is a leading advocate of single payer health care, does not advocate the Canadian system. We advocate Canada Deluxe. We advocate spending the same amount what they’re spending now twice what they have in Canada, but achieve the administrative efficiency and universal coverage of Canada, so we could cover everyone with no waits of any type. But getting back to the question of Bush and Kerry, Mr. Kerry gets us less than halfway there, even if his plan is successful. He will leave 17 million Americans with no health insurance. Let’s not pretend that’s really universal health care.

Mr. Bush’s plan is actually quite a bit worse. He intends to pour money into tax credits which will not succeed in covering people. We know that because Mr. Bush is modeling his plan after an existing tax credit program called the Trade Adjustment Assistance Act, where less than 2% of eligible people have decided to take the tax credit. The reason is that Bush is talking about offering a tax credit of $3,000 for a family to buy health insurance. But the average family policy in this country costs $10,000. This would leave a family with $7,000 they would have to take out of their own pocket in order to get health insurance. And obviously, a low income family, an unemployed family, is not in a position to pay an additional $7,000 out of their pocket for health care. Hence the tax credits are not going to be sufficient to allow low income people to buy health insurance and they’re simply not going to get any coverage out of Mr. Bush.

JUAN GONZALEZ: Sally Pipes, your response, especially on the whole issue of the administrative cost savings as a result of the plans of Senator Kerry; and doesn’t a bigger, more organized system with one buyer have power to control prices better and to prevent health care costs from spiraling?

SALLY PIPES: The Canadian system is expensive. First of all, you’re comparing apples with oranges. Canada doesn’t include the capital costs of hospitals in their numbers.

DR. STEFFIE WOOLHANDLER: That isn’t true.

SALLY PIPES: Excuse me. Canada has the third most expensive health care system in the world after the United States and Switzerland. Canadians, if you look on websites, you will see the stories of Canadians who are having to wait, who cannot get doctors and are leaving Canada to come to the United States. There’s a woman in Quebec, who is suing the Quebec government in a malpractice suit for $37 million. She’s suing on behalf of 10,000 Quebec breast cancer patients who had to wait over the limit of eight weeks to get radiation oncology. The Canadian Medical Association came out with a report two weeks ago saying that over 50% of Canadians are incredibly dissatisfied with the health care that they are getting, just look on websites and see the number of Canadians who are upset. And Canadians use America as a safety valve. Look at the border towns. Senator Ed Lawson, who was head of the Teamsters union, and became national senator, when he was diagnosed two years ago with heart situations similar to president Clintons, they told him to wait, even a person of such importance as himself, left and came to — went to Seattle, Washington, because he didn’t want to wait two weeks to get an angiogram. So,you know, I’m not a crackpot institute. That was very insulting. I have done a lot of work. I have worked in Canada on this issue. There is tremendous work done by the Frasier Institute in Canada on hospital waiting lists. It’s all scientifically done. The administrative costs in Canada, you’re not comparing apples with apples it is the third most expensive system in the world.

In the United States today, 45% of our health care dollars are actually in the government system between Medicaid, Medicare, the State Children’s Health Insurance Program and things like that.

DR. STEFFIE WOOLHANDLER: I’m not calling Sally a crackpot. I’m calling Frasier Institute that she quotes extensively crackpot. This is the group that thinks we ought to privatize the whales. This is a group that thinks that we should abolish medical licenses.

SALLY PIPES: This is a group that thinks there should be private options in Canada. I think a lot of people in the United States think that Canada

DR. STEFFIE WOOLHANDLER: Sally, I let you talk, okay. Now it’s my turn. The reality is Canada spends half of what we do. I happen to have published a definitive article on the administrative costs in the New England Journal of Medicine. I know what the Canadian hospital cost reports look like. I know what Canadian cost reports look like. Canada spends half of what we do. That’s what the Organisation for Economic Co-operation and Development and the UN say. And that’s the reason why they do have some waits for elective services in Canada. Elective services. Do think that’s a good thing? No. I don’t think we should have to wait for things. But if we have a Canadian style system, and spend twice as much money, then there’s no reason to have any waits. That’s not just my opinion, that’s also the opinion of the US General Accounting Office and the US Congressional Budget Office.

AMY GOODMAN: I’d like to ask Sally Pipes, what do you think is good about John Kerry’s proposal?

SALLY PIPES: Well, I don’t think that there are good things about it. I think the numbers came out from the Census Bureau saying that 45 million America ns do not have insurance. You have to look and analyze who are the 45 million Americans. Because 16% of them are people who are earning over $75,000. 33% are people who are earning over $50,000. Just because you don’t have health insurance does not mean that you don’t get health care. There’s a lot of money spent by individuals who don’t have health insurance who go out and buy their own. They pay out of pocket for their health care. Really, 8 million Americans are people who are chronically uninsured, and low income. Those are the people that I think that the government needs to take care of. And I definitely believe that there are — you know, children and low income families that do need care. I think for the rest of people, we need to open up system to empower consumers to get the best health care they can. People, when you look at any government program, most people do not like the DMV. The post office became more competitive when it opened up to competition from fed ex and UPS and a variety of things. Competition is what makes the world go around. Canadians do not have any form of competition. Any private coverage in Canada is outlawed under the Canada Health Act.

JUAN GONZALEZ: Let me ask you, Sally Pipes, drugs, the cost of prescription drugs have become a huge part of health care costs in this country, and if our system, as it is now structured, is doing so well, why are so many Americans trying to get to Canada, or to Mexico to buy prescription drugs?

SALLY PIPES: Today in America, Americans spend 1% of their income on prescription drugs. In the 1960’s Americans spent 1% of their income on prescription drugs. There are a number of drugs that are available in Canada– in the United States that allow us to — many — the drugs today allow us to live longer and healthier lives. From 1997 to 1999, out of 100 new drugs that became available in the United States, only 43 of them made it onto the formular
y in Canada. A lot of the top drugs in the United States that are used in Canada are generically available in the United States, and are cheaper, but the real issue here about prescription drugs, Americans want lower prices for prescription drugs. The reason they’re — the drugs are lower in Europe and Canada is because of price controls. So, what people really want in America is price controls on drugs, which is going to have a negative impact on research and development in this country, and innovation. New drugs have reduced costs for hospital stays because people can use drugs now for ulcers, for instead of having gall bladder surgery. We’re reducing costs by allowing Americans to have access to the greatest drugs and innovation in the world.

JUAN GONZALEZ: Dr. Steffie Woolhandler, I’d like you to respond to the issue of drugs and the differences between Canada and the United States.

DR. STEFFIE WOOLHANDLER: I want to remind that you, Canadians do live two to three years longer than Americans. That was not true before they went with National Health Insurance. That’s because the National Health Insurance program has allowed them good access to all types of care, including drugs. Canadians, about half of Canadians do get their drugs through their insurance. But all Canadians benefit from a system whereby the government negotiates with drug companies for lower prices. So, Canadians are paying about 60 cents on the dollar that Americans pay, and they’re paying only 60% of what we pay for drugs, and they really are the same drugs. Sally’s idea that you cannot get drugs in Canada is simply not true.

SALLY PIPES: I’m not saying you can’t get drugs.

DR. STEFFIE WOOLHANDLER: They have access to the same drugs that we do, they can just afford them. And similarly, Sally’s contention that uninsured people get all of the health care they need, doesn’t make common sense, but is also belied by a huge body of literature. Most recently, Ayanian colleagues published a study looking at people aged 55 to 65 who have no health insurance, and 10% of the people died over an eight-year period. They died at 33% higher rate than people who had insurance. It’s just common sense that if you don’t have a way to pay for care, you are going to get less of it, and it’s going to impact your health and maybe make your die younger.

AMY GOODMAN: Who benefits under Bush’s plan?

DR. STEFFIE WOOLHANDLER: Well, there’s a big benefit to some middle income taxpayers who end up taking a tax credit where they already had insurance. Now, they can get a tax credit that helps them pay for it. So, there’s some benefit to that. He’s very big, in general, Bush’s policies are very big with the insurance industry and drug industries. Because he has a very hands-off approach, where all of the government taxpayers do is just send more money into the system. There’s no attempt by the government to regulate things or make them more fair.

AMY GOODMAN: Sally pipes?

SALLY PIPES: Well, I’d like it just comment on one thing. Canada is a country of 32 million people, fewer than in the state of California. We have much less ethnically diverse. We don’t have the minority low income populations that are in the United States. If you compare white Canadians to white Americ ans, Americans are now living longer than Canadians. I think that the Bush plan

DR. STEFFIE WOOLHANDLER: No, that isn’t true, Sally. It’s simply not true. Canada Health Survey .

AMY GOODMAN: We actually have to leave it there. I want to thank you both for being with us. I know that you both have to race off anyway. Sally Pipes, president of the San Francisco based Pacific Research Institute. Her new book is called Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer. Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard University, and co-founder of Physicians for a National Health Program.

On health, a clear choice between Bush, Kerry

On health, a clear choice between Bush, Kerry
October 17, 2004

The health care crisis is back. It’s a lively topic in the presidential campaign.

Eleven years after the Clintons introduced their super-complex plan to revamp health care, the problems of rising costs and increasing numbers of uninsured have only gotten worse.

More than 43 million citizens under the age of 65 do not have health insurance – up from 38 million a decade ago. And fewer employers provide health insurance plans at all. Four years ago, 65 percent of employers offered health plans. Today it’s 61 percent.

In addition, health care costs continue to skyrocket – well beyond the rate of inflation. Since 2001, premiums for family coverage have risen 59 percent, according to a recent Kaiser Family Foundation survey. That’s five times the rate of inflation and well above the increase in income for the average worker. For employers, it adds to the cost of doing business and discourages hiring new employees.

And the trends are ominous. Spending on health care now accounts for almost 15 percent of the nation’s gross domestic product – and rising. Japan and Great Britain spend 8 percent. And the United States has fallen behind other nations in significant measures of health. For instance, the infant mortality rate for black Americans is double the rate for whites and four times that for babies in Japan.

The health care proposals by President George W. Bush and his Democratic challenger, Sen. John Kerry, are dramatically different in type and scale.

While Kerry’s plan is far short of the scope of the Clinton administration’s proposal – and not a Big Government plan as Bush charges – it is ambitious and expensive. Kerry wants to cover 95 percent of the population; he estimates it would cost $653 billion over nine years. He would pay for it by rolling back the tax cuts for people earning more than $200,000 a year.

Kerry’s plan includes tax credits to small businesses to enroll in the federal employees health care system – a group of private plans. He would lower premiums by having the government re-insure for catastrophic coverage – the fastest growing aspect of health insurance. And he would extend government coverage to all children not covered.

Bush’s plan is far less ambitious. It basically involves offering health savings accounts that would allow individuals to deduct the costs of health insurance from their taxes. The major problem with his scheme is that middle-income and working-class families might not be able to afford to pay into the accounts.

It would certainly benefit the wealthy. And the Kaiser foundation estimates it would only reduce the uncovered rolls by 1.8 million.

Bush says Kerry’s plan would cost three times what Kerry estimates and require a tax increase. Maybe so. And the Kerry plan would be more effective in providing additional coverage than reducing medical costs. But Bush’s plan doesn’t meet the challenge of either rising costs or lack of coverage.

Inevitably, reducing costs will involve tough moral and ethical questions, the kind that politicians running for office aren’t willing to deal with. The nation has developed more medical technology than it can afford. The key issue in controlling costs will be: who gets what type of care, and when. That does imply rationing.

This much is clear: The next president will have to step up to these issues. In our view, the Kerry plan offers more hope for making progress.

Controlling Health Care Costs

By Paul B. Ginsburg, Ph.D.
The New England Journal of Medicine
October 14, 2004

In reality, there are four basic options for slowing the trends in health care spending: one can increase the efficiency of health care delivery; increase the financial incentives for patients to limit their use of medical services; increase the administrative controls on the use of these services; or limit the resources available to the health care system.

Government may be able to contribute to the efficiency of the health care system by supporting the development and installation of information technology to improve the coordination of patient care… Greater adherence to the practice of evidence-based medicine, additional research on the effectiveness of medical treatments, and greater assessment of technology before it is used outside research settings may all lead to gains in efficiency…

In recent years, employers have taken such steps as increasing deductibles in order to shift more costs to employees, giving them a financial incentive to use fewer services. Innovation is under way in this area: new benefit structures have been developed, including consumer-directed health plans, which typically have employer-funded spending accounts tied to insurance policies with a large annual deductible that exceeds the annual contribution to the account. Having patients share more costs can benefit consumers when it leads them to forgo care that has very limited benefits. But when the tools are used bluntly – as when they are applied equally to care that is deemed essential and care that is considered to be more discretionary – they can pose a barrier to important care or cause financial hardship for patients with low incomes or substantial medical needs.

An approach stressing administrative controls, relying on tools such as restrictive provider networks, prior authorization for services, and payment of providers on a capitated or episode basis, was used extensively by managed-care plans but proved highly unpopular.

Restricting the resources that go into the medical care system and the prices paid to providers is an approach that has been used extensively in Canada and Western Europe but has never gained much of a foothold in the United States. Attempts to regulate facility expansion and hospital rates were common in the United States during the 1970s but declined with the expansion of managed care and increased competition in medical care.

We can only hope that whoever is elected president will move beyond campaign-trail rhetoric and provide the leadership needed for a candid national discussion about health care costs. If not, we will find ourselves on a downward spiral, as more and more resources are used to pay for the health care of fewer and fewer Americans – a potentially intolerable situation.

http://content.nejm.org/cgi/content/full/351/16/1591

Comment: Quiz time. There are many ways to control health care costs. Regular readers of the Quote of the Day messages should be able to identify which measures will slow the growth of health care costs while ensuring that each patient will have affordable access to higher quality health care services, and which measures will slow the growth of costs by making care unaffordable to individuals with significant health care needs, while failing to direct our resources to care which is less costly but with better outcomes.

You have ten minutes to select the beneficial approaches and discard those that are detrimental. When finished, aggregate your answers and then share them with others as you initiate your own efforts at grassroots reform. Without your participation, reform won’t happen.