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Medical Class Warfare

Medical Class Warfare

By PAUL KRUGMAN.
E-mail: krugman@nytimes.com

If past patterns are any guide, about one in three Americans will go without health insurance for some part of the next two years. They won’t, for the most part, be the persistently poor, who are usually covered by Medicaid. They will be members of working families with breadwinners who have jobs without medical benefits or who have been laid off.

Many Americans fear the loss of health insurance. Last week I described John Kerry’s health plan. What’s the Bush administration’s plan?

First, it offers a tax credit for low- and middle-income families who don’t have health coverage through employers. That credit helps them purchase health insurance. The credit would be $3,000 for a family of four with an income of $25,000; for an income of $40,000, it would fall to $1,714. Last year the average premium for families of four covered by employers was more than $9,000.

A study by the Kaiser Family Foundation estimates that the tax credit would reduce the number of uninsured, 44 million people in 2002, by 1.8 million. So it wouldn’t help a great majority of families unable to afford insurance. For comparison, an independent assessment of the Kerry plan by Kenneth Thorpe of Emory University says that it would reduce the number of uninsured by 26.7 million.

The other main component of the Bush plan involves ”health savings accounts.” The prescription drug bill the Bush administration pushed through Congress last year had a number of provisions unrelated to Medicare. One of them allowed people who purchase insurance policies with high deductibles, generally at least $2,000 per family, to shelter income from taxes by setting up special accounts for medical expenses. This year, the administration proposed making the premiums linked to these accounts fully tax-deductible.

Although the 2005 budget presents that new deduction under the heading ”Helping the uninsured,” health savings accounts don’t seem to have much to do with the needs of the families likely to find themselves without health insurance. For one thing, such families need more protection than a plan with a $2,000 deductible provides. Furthermore, the tax advantages of health savings accounts would be small for those families most at risk of losing health insurance, who are overwhelmingly in low tax brackets.

But for people whose income puts them in high tax brackets, these accounts are a very good deal; making the premiums deductible turns them into a great deal. In other words, health savings accounts will offer the already affluent, who don’t have problems getting health insurance, yet another tax shelter. Meanwhile, health savings accounts, in the view of many experts, will actually increase the number of uninsured.

This perverse effect shouldn’t be too surprising: unless they are carefully designed, medical policies often have side consequences that worsen the problems they supposedly address. For example, the Congressional Budget Office estimates that one-third of the retirees who now have drug coverage through their former employers will lose that coverage as a result of the Bush prescription drug bill and will be forced to accept inferior coverage from Medicare.

In the case of health savings accounts, the key side consequence is a reduced incentive for companies to insure their workers. When companies provide group health insurance, healthier employees implicitly subsidize their sicker colleagues. They’re willing to do this largely because the employer’s contributions to health insurance are a tax-free form of compensation, but only if the same plan is offered to all employees.

Tax-free health savings accounts and premiums would provide healthier and wealthier employees an incentive to opt out, accepting higher paychecks instead, and would lead to higher insurance premiums for those who remain in traditional plans. This would cause some companies to stop providing health insurance, or raise employee contributions to a level some workers can’t afford.

The difference couldn’t be starker. Mr. Kerry offers a health care plan that would extend coverage to most of those now uninsured, paid for by rolling back tax cuts for those with incomes over $200,000. President Bush offers a tax credit that would extend coverage to fewer than 5 percent of the uninsured, plus a new tax break for the affluent that would actually increase the number of uninsured. As I said last week, I don’t see how Mr. Bush can win this debate.

Coalition for Health Coverage forms in Southhampton

The Southhampton Press
June 24, 2004

By Kathleen Fitzpatrick

Members of the newly formed Coalition for Health Coverage in Suffolk held a vigil outside Southampton Hospital’s emergency room on Saturday in solidarity with thousands of protesters across the country who called attention to the millions of Americans who don’t have health insurance.

“This is a story that is playing out all over the U.S.,” said Kathleen Madigan, the eastern Long Island outreach coordinator for the Women’s Health Partnership, referring to the national day of action calling for government action. “There are people out here on the East End who are working three jobs and can’t afford health insurance.”

East End activist Michael O’Neill of the Unitarian Universalist Church said he’s 68 years old and can’t afford health insurance or dental care. “I have to hope I don’t get sick,” he said. “Medicine should not be a privilege.”

According to Families USA, a non-profit organization dedicated to achieving health care for all Americans, more than 75 percent of uninsured New Yorkers are members of working families. The remaining New Yorkers are either seeking employment or are not in the labor force because they are chronically ill, disabled or caregivers.

The coalition of South Fork organizations, which formed two months ago, is “pulling together to ring the bell” on the health insurance emergency in this community, said Ms. Madigan.

James S. Henry, author and investigative journalist, served as spokesperson for the coalition. “This group is coming together to start organizing on issues of concern to people who are not insured, but also to hospitals facing financial crisis in treating those who are uninsured, and the rest of us living in a population where doctors are not doing preventative care,” he said. “Seventy-two million Americans experienced a lack of coverage within the last two years. We’re making an effort to educate people to build support for specific policy changes at all levels.”

A bill championed by many at the vigil, the National Health Care Act, also referred to as Expanded Medicare for All Americans, has 30 sponsors in Congress. Dr. Elaine Fox of Physicians for National Healthcare who had a practice for 17 years in Southampton, has taken time off to be an activist, and supports the bill. She explained that the act would cover everyone under the “old-fashioned” Medicare.

“Medical administration costs would be 3 percent; right now, it’s at 10.25 percent with all other insurance plans,” she said. “The country would save $280 billion a year. That money is enough to cover all of the uninsured, to cover prescription drugs, and also cover those who are underinsured.”

Dr. Fox said that this bill would not cause an increase in health care spending. “Bush’s bill increases spending by $550 billion,” she said. “The reason that [this bill] has not passed yet is because of profits. Profit motive has no place in health care. Patients come before profits.”

The current system is profit-driven, not patient-driven, according to Mr. Henry. He said that such a system doesn’t work.

“Employer-based health care system is not doing the job,” he said. “Costs have risen 10 percent a year for the last decade. As a country, a larger share of our national income is going to pay health insurance, more than in any other country. Fifteen percent of our [Gross Domestic Product] goes toward health insurance. In European countries and in Canada they pay less than half of that.”

Mr. Henry explained that one of the problems with the medical market is that it’s not competitive. “It’s not the kind of market you expect to work well without regulation,” he said. “Consumers don’t know enough to evaluate their own care. Suppliers don’t have to compete. The people paying the bills—insurance companies—are not the ones receiving the care.”

“Those of us in this coalition believe health care should be viewed as a human right,” said Mr. Henry. “A lot of Americans wake up every day with this on their mind. People are losing their businesses. Small businesses are having a hard time competing. Hospitals like this one are in trouble.”

According to Donna Sutton, Southampton Hospital’s director of public affairs, in 2003 the hospital reported $1.3 million in “charity care,” free care provided to patients who are not expected to pay medical bills. In Suffolk and Nassau counties, there is a law that requires hospital to have a “charity care” program.

At Southampton Hospital, the amount of aid provided is based on need, which is determined by income and family size. The highest eligible income is twice the federal poverty level. The hospital actively screens those who could benefit from charity care, she said.

The hospital also reported $6 million in uncompensated care—expenditures not collected due to insurance companies not covering the bills and/or patients who the hospital expected would pay but who didn’t. The hospital’s total revenue for 2003 was about $80.7 million.

Dr. Allen Fein, who has a practice in Southampton, emphasized that the coalition was not attacking the hospital. “Hospitals are caught in a system where they aren’t being paid for the care they provide,” he said. “There’s very little good will between hospitals and insurance companies.”

Dr. Fox said that a disproportionate number of people of color are without health insurance. According to the coalition’s press release, 32 percent of Hispanics living in the United States are uninsured; 10 of the 13 million uninsured Hispanics are in working families. Twenty percent of black Americans and 18 percent of Asians are uninsured, compared with 11 percent of whites.

Most immigrants on the East End do not have health insurance—an issue the coalition will work on.

“If our goal is to provide care for everyone, and we want to include the immigrant community as well,” said Mr. O’Neill. “It is an injustice that they pay social security taxes and they’re not eligible to receive that money if they return to their home country.”

Ms. Madigan said the group would begin to meet regularly. “The next steps are for us to have an organizing meeting to formulate positions on this,” she said.

Currently the group is working on filming a documentary, “On the Edge: Living Without Health Insurance,” which highlights health insurance issues on the East End. The group hopes to have it finished by the fall, she said.

Medicare cards little help

Medicare cards little help
Dawn MacKeen
STAFF WRITER
July 15, 2004
Seniors in Nassau County can save more money purchasing top-selling medications through Canada and the Veterans Administration than with a new Medicare-approved drug card, according to a Congressional committee report issued Wednesday.

Democrats in the House Committee on Government Reform analyzed discounts offered by the 34 different cards in Nassau County. They found, for example, that seniors can get their prescriptions filled for almost the same price online at the Web site drugstore.com. “I think seniors should care because the federal government will be spending more than $500 billion to give them a prescription drug card that is not working,” said U.S. Rep. Carolyn McCarthy, who represents Nassau County and requested the study.

Seniors were able to start using the cards, which offer discounts of up to 18 percent on brand-name drugs, on June 1. Although there are no local numbers, the federal agency overseeing the program, the Centers for Medicare & Medicaid Services boasts 3.8 million enrollees nationwide, most of whom were signed up automatically.

Peter Ashkenaz, the agency’s spokesman, defended the program. “The cards are showing real savings,” he said, pointing out that the new report primarily compared the program to mail-order pharmacies, such as drugstore.com or ones in Canada. “And remember that most seniors prefer to buy their drugs at their neighborhood drug store.”

To many senior advocates, the results of the congressional study were hardly surprising. The recent findings mirror other studies examining the savings offered by the cards nationwide. The congressional study found that in Canada, a 30-day supply of Celebrex, an arthritis drug, costs $38.69 compared with the Medicare drug card’s $74.14. And through the Veterans Administration, for example, the acid reflux medication Protonix costs $44.31, in contrast to the card’s $68.71.
The new report says the only people who can benefit from the cards are low-income seniors, who don’t have to pay the annual fee of up to $30 for the card. Once a person enrolls, he or she can obtain a $600 credit to apply toward the purchase of prescription drugs. But to qualify for the subsidy, a person must earn less than $12,569 and a couple less than $16,862.

“The low-income are getting the benefit of the $600, but that’s really a small percentage,” said Roberta Monat, director of Long Island’s Jewish Association for Services for the Aged. “Most of our people have not even gotten them [the cards]… It’s much too confusing, convoluted, seniors can’t figure it out.”

In fact, more than 100,000 low-income seniors already in Elderly Pharmaceutical Insurance Coverage (EPIC) were automatically enrolled in First Health Services Corp.’s Medicare card program. That card saves the user less than any other, according to the report. “Our EPIC program receives drug manufacturer discounts on prescriptions, and the federal drug discount program is bringing additional cost savings,” said Rob Kenny, a state health department spokesman. But consumer advocates point out that the cards that offer the least savings can deplete a senior’s $600 subsidy faster.

“The Pataki administration should ask some very hard questions as to why the card it selected offers the worst deal,” said Robert Hayes, president of the Medicare Rights Center, a Manhattan-based consumer group.

Letters to Elected Officials

June 23, 2004

Dear Senator Alpert,

I am writing today to express my strongest possible support for SB 921, the single payer health care initiative authored by Sheila Kuehl (D-23)

In January 2004, a committee of the National Academy of Sciences estimated
that every year, 18000 Americans die needlessly as a result of having
inadequate or no health insurance. To put that into perspective in the words
of our times, that is a new September 11th tragedy every two months. A tragedy
that is entirely self-inflicted, and persisting for as long as we don’t fix our broken health care ‘system.’ Roughly 10% of those people die in California, based on our percentage of the nation’s population.

It’s time for everyone to have healthcare, and SB 921 provides a solution. I ask you to do everything in your power to support this bill and to seek solutions to provide EVERY Californian with health care.

Sincerely,

Myles Sussman, PhD
Member, Physicians for a National Health Program
8840 Costa Verde Bl #3445
San Diego, CA 92122
858-546-1142

Jim Sykes Announces Health Plan

Jim Sykes Announces Health Plan
By bshepard@ktva.com!
Brett Shepard
Tuesday, July 13, 2004 – US Senate candidate Jim Sykes has ambitious plans for Alaska’s health care system if he gets elected.

According to Sykes contributions from medical and insurance companies have dictated the health care platforms for his fellow competitors Tony Knowles and Lisa Murkowski.

He says we need to get the health care money out of the campaign system in order to make progress towards lower cost in the system.

Sykes solution for lower health care cost would be to create a single-payer national health care system.

“We need a single-payer system. Imagine a country, our country I hope, where you can take your health care card, like they do in Canada, and you see the physician y! ou want to see and you get the help you need and it’s payed for by a universal insurance pool. That is what we need.”

Sykes said this system would help control the continually rising cost of health care in this country.

We contacted representatives with the Murkowski campaign and they said this type of system wouldn’t work in the US.

The Knowles campaign representative said one the key components of Knowles campaign to help lower health care cost would be to import drugs from Canada.

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The New Economics of Being Young

The New Economics of Being Young
by Solana Pyne
One Sick Fall
With health insurance out of reach, a generation braces itself for the worst
July 13th, 2004

If they’re not outright poor as a class, young adults in this country are at least very, very broke. The average collegian graduates with more than $20,000 in debt, headed for a job market where real hourly wages have kept pace with neither inflation nor the cost of living. Young adults are broke in part because of their unprecedented schooling”in the latest census figures, 28 percent of those between 25 and 29 reported holding a bachelor’s degree”which promised to pluck them away from the constellation of problems plaguing America’s underclass, whether it was trouble with housing or inadequate medical care.
Yet there they are, these latest inheritors of the American dream, lined up in emergency rooms for toothaches and the flu, not because they’re having emergencies, but because they don’t have health insurance, and emergency rooms, unlike private doctors, are obliged to give them care. Since 1987, the number of uninsured young adults has grown at twice the rate of older adults, even though the demographic itself is shrinking. One-quarter to one-third of adults under 35 went without insurance for all of 2002, the most recent year for which statistics are available”an increase of 1.2 million from the year before. Half were uninsured for some part of 2002. Of the 43.6 million uninsured adults in the U.S., 41 percent are young.

Of all the rationales John Kerry and George Bush will give this year as they stump for their individual visions of helping the nation’s uninsured, one of the most pragmatic is that those little plastic cards can make the difference, for a crucial group of consumers, between having a financial parachute and cratering into debt.

Maria Davidson, of Meriden, Connecticut, was 26 and working for low pay with no benefits when her seven-year-old son tried to kill himself. The ambulance took him to Yale-New Haven Hospital. She had no private coverage for herself and her family. Her children were not eligible for public plans, and she wasn’t aware of programs that could have covered the hospital expenses. Her son amassed $3,900 in bills that Davidson just couldn’t pay. That was nine years ago. By the time the bill was resolved as the result of a lawsuit, she owed, with interest, over $6,000. Collection agencies were garnishing her wages and had put a lien on her condo.

Much of her story is sadly typical. A survey published in May by the Commonwealth Fund, a nonprofit based in New York City, found that of the uninsured between 19 and 29, half had trouble making payments, had been contacted by a collection agency, or had modified their lifestyles to pay off medical bills.

And the cost hardly stops with lost purchasing power. The Commonwealth Fund’s survey found that more than half of those young and not covered had gone without needed medical care in the last year, which included not seeing a doctor, failing to fill a prescription, or skipping a recommended medical test, treatment, or follow-up visit.

Long Islander Fred Gumm, 26, now has health insurance through his job at Starbucks, which, he said, is “pretty much the only reason I work there.” He went without coverage for two and a half years, during and after school at SUNY-New Paltz. While uninsured, he broke a few fingers and injured his shoulder and his back. He didn’t go to the doctor because he couldn’t afford the bill, and as a result, the injuries healed badly and still trouble him.
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The story for middle-class kids these days is that you’re covered by your family’s insurance until you graduate college, and then you’re on your own. For those not in school, the cutoff comes even sooner. “You turn 19 and lose your parents’ coverage,” said Sara Collins, an economist for the Commonwealth Fund.

In theory, you quickly get a job that comes with insurance. That’s the way our system is designed to work, with employers rather than the government providing coverage. But as premiums have risen, companies have begun to consider forgoing health plans. In September, the trade journal BenefitsNews.com reported that among companies with 10 to 49 workers, the percentage of those offering insurance dropped from 66 percent to 62 percent. That four-point dip may not sound like much, but the journal estimated it could represent some 200,000 businesses. What’s more, young people tend to work for smaller firms” think entrepreneurial start-ups”and only 55 percent of companies with fewer than 10 workers carry health plans. A May 2003 report by the Commonwealth Fund found that 65 percent of working young adults are eligible for an employer-sponsored plan, compared to 77 percent of older adults.

What looked like a relatively seamless transition for your parents looks for you like a rickety bridge. You’re not making much money, you’ve got student debt, the job market stinks, and what jobs exist aren’t promising much. “The kinds of jobs you’re eligible for are the kinds that often don’t come with health insurance,” Collins said.

America’s approach to paying for medical care stretches back to World War II, when regulations made accident and health insurance for employees tax-exempt. Meanwhile, a simultaneous wage freeze and worker shortage encouraged employers to offer insurance as a perk to attract labor, explained Ken McDonnell, a research analyst with the Employee Benefit Research Institute.

During the same period, England instituted universal coverage. The reasons we didn’t are a complex knot of social and political influences now nearly impossible to untangle. “I think part of it is who’s being served here. In more homogeneous societies, like in Scandinavian countries, [universal health care] came as a no-brainer,” said David Jones, the president of the Community Services Society, a New York nonprofit. “But we’re not homogeneous. There’s a sense that ‘We’ve got ours, I’m not sure I want to give it to those guys.’ ” As employer-sponsored insurance took hold, the number of uninsured dropped steadily, reaching an all-time low of 23 million in 1976. But the very availability of good care quickly drove premiums up. In the 1980s, health care costs exploded, with annual increases peaking at 18 percent in 1989, before slowing briefly in the 1990s. Increases hit the double digits again in 2001, and reached 13.9 percent last year.

Perhaps not surprising, companies began to balk at providing benefits, leading individuals”the self-employed, the unemployed, the employed but not covered”to go it alone. Reforms designed to help the older and sicker buy private insurance served to further squeeze the able-bodied but vulnerable. Prices today are all over the map. A young, healthy adult in California can find basic catastrophic coverage for under $100 a month, but the same person could have to pay $280 for a similar plan in New York, largely due to differing state regulations.

For Lars Russell, in his early twenties, the cost of health insurance came as a shock. He graduated last year from the University of Michigan and moved to New York. “It’s not really anything I can afford,” he said in November. “I don’t even have car insurance right now.”
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Russell would get little sympathy from McDonnell, the benefits research analyst. “That’s life,” he said, when asked about the huge number of uninsured young adults. “If you’re young and healthy, you’re going to take risks. It’s life everywhere.”

McDonnell cited an unwillingness to pay for insurance as a big reason young adults go without coverage. It’s a fine line, however, between being unwilling to pay even $100 a month and being unable to. And it’s significant that when offered health insurance by an employer in exchange for a deduction from each paycheck, 74 percent of young adults take it, just a hair less than the 79 percent of older adults who do the same. “The argument is that if it’s that important to you, then get a job that offers health insurance,” said McDonnell, who, like so many experts on health care issues, is over 35 and has long had jobs with good benefits.

Janet Murray “who asked that her name be changed because of pending litigation” followed McDonnell’s advice. Now in her late twenties, she was born with hypothyroidism and takes daily medication. During her first year of college in upstate New York, she contracted Lyme disease. Because she caught it early, she doesn’t need constant treatment, though she is prone to exhaustion and respiratory infections like pneumonia. Her health problems don’t prevent her from working, but they make it impossible for her to do without good insurance. Murray studied film in college but gave up on her dream of working in movie production. Instead, she took an office job with a media company because it came with benefits.

“I think the biggest thing for me was, if I had the stamina and I didn’t have the general expenses of being on a bunch of medication, I would have taken more risks,” Murray said. “I feel like I don’t really have that luxury.”

Maybe her dreams wouldn’t have panned out, but the American health care system has made it nearly impossible for her even to try. Or maybe Murray is lucky. At 21, Pedro Jimenez of South Williamsburg said he has never had health insurance at all. “I don’t really know anything about it, to be honest,” he said. When necessary, he has gone to the emergency room and tried to pay off the bills in installments. Otherwise, he has avoided going to the doctor. But basically, he has avoided thinking about the dangers, focusing instead on looking for work, getting his GED, and going to college.

It’s important to note that degrees of coverage vary greatly by race: African Americans were nearly twice as likely as non-Hispanic white people to be uninsured in 2002, and Latinos three times as likely.
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Not having a job with benefits can mean being forced to choose between health insurance and other expenses, some of them critical to building a so-called life. Young adults “are in a stage where people have debts from school, they are trying to buy a house, and that seems more important than paying for health insurance, which might cost multiple thousands each year,” said Robert Blendon, a professor of health policy and political analysis at Harvard University.

The types and prices of plans for sale vary dramatically by state, largely according to regulations. Premiums nationwide for those under 35 average about $136 per month, according to eHealthInsurance, a website that sells individual and family insurance. Many states have plans with premiums below $100 for young, healthy adults without any pre-existing conditions. Cheaper plans are usually for emergencies only, don’t cover routine doctor visits, and carry four-digit deductibles.

At age 22, Kristen Gass had minor outpatient surgery to remove pre-cancerous cells from her cervix. At the time, she was working as an actress and had health insurance through the Actors’ Equity Association, a union that represents actors and stage managers working in theater. Soon after, she moved back home to Los Angeles, took a break from acting, and lost her coverage. When she looked into buying a policy, insurers quoted monthly premiums hundreds of dollars higher than she was able to afford, citing her recent surgery and a family history of cancer. They told her she would have to be without symptoms or treatment for at least two years before premiums would drop. So she went without.

“I just didn’t go to the doctor,” Gass said. “I went once for a checkup and that was it. I realized how much it would cost.” Had she been in New York, the cost of individual insurance would have been the same regardless of her history. But she still couldn’t have afforded it.

Only one New York insurer has posted a plan on eHealthInsurance, at am monthly premium of $280. The plan covers hospitalization but not doctor visits. According to the New York State Insurance Department, basic HMO plans start at $320 a month. The self-employed may be able to get insurance at group rates through organizations in their field. One of the more popular comes from the Freelancers Union “part of Working Today” which offers HMO coverage, including vision and dental, for $286 through Health Insurance Plan of Greater New York.

Just as race plays a factor, so does gender. By the time he reaches age 34, the average Joe earns $30,677, and could expect to pay 11 percent of that gross for the cheapest plan in New York. The average Jane, earning $21,649, would fork over 4 percent more.
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If the cost of insurance is unbearable, so is the cost of not having it. Even common injuries can be financially debilitating for people still trying to get on their feet. Manhattan resident Drew Brown, uninsured and unemployed, went to the emergency room at Beth Israel for a toothache and left with a prescription and a $500 bill. Brooklynite Andrea Craig had to pay $2,000 for surgery to treat a mouth infection before she got insurance through her current job. Some people have almost gotten used to it. “If I get sick, I go to the emergency room. I usually give them my real name. I get bills. If they are reasonable I pay them. If not “if they’re, like, four or five grand”I ignore them,” said a 35-year-old Manhattan photographer who refused to give his name.” The emergency room is the only place I go. It’s the only place that’s free.” High numbers of uninsured strain hospital budgets because emergency rooms can’t deny care to those who can’t pay, Harvard professor Blendon said. Disease outbreaks are worsened when a significant fraction of the population doesn’t have insurance. “We’ve lucked out because we haven’t had any big epidemics, but with SARS and anthrax it really struck experts that you are going to have people getting sick and not going to the doctor,” Blendon said. “Canada didn’t have that problem.”

The only real fix is universal health care, said Ken McDonnell, and with the current political climate, he says, such a policy has “a snowball’s chance in hell.” Estimates of the cost range from a net savings to a new burden of trillions. A study published by the journal Health Affairs estimated that extending coverage to the uninsured would lead to extra spending on the order of $33.9 billion to $68.7 billion each year as the newly insured sought additional medical care.

Short of universal health care, most reforms still leave young adults at risk. For now, many go it alone, scrounging up care where possible and resigning themselves to the hope that lighting won’t strike. After all, millions of people do it.

Willingness of the insured to cover the uninsured

Journal of General Internal Medicine
August 2004
Will Insured Citizens Give Up Benefit Coverage to Include the Uninsured?
By Susan Dorr Goold, MD, MHSA, MA, Stephen A. Green, MD, MA, Andrea K.
Biddle, PhD, MPH, Ellen Benavides, MHA, Marion Danis, MD

OBJECTIVE: To describe the willingness of insured citizens to trade off their own health benefits to cover the uninsured.

DESIGN: Descriptive study of individual and group decisions and decision making using quantitative and qualitative methods.

SETTING AND PARTICIPANTS:Twenty-nine groups of citizens (N= 282) residing throughout Minnesota.

INTERVENTIONS: Groups participated in Choosing Healthplans All Together (CHAT), a simulation exercise in which participants choose whether and how
extensively to cover health services in a hypothetical health plan constrained by limited resources. We describe individual and group decisions, and group dialogue concerning whether to allocate 2% of their premium to cover uninsured children in Minnesota, or 4% of their premium to cover uninsured children and adults.

MEASUREMENTS AND MAIN RESULTS: While discussing coverage for the uninsured, groups presented arguments about personal responsibility, community
benefit, caring for the vulnerable, social impact, and perceptions of personal
risk. All groups chose to insure children; 22 of 29 groups also insured adults.
More individuals chose to cover the uninsured at the end of the exercise, after group deliberation, than before (66% vs 54%; P < .001). Individual selections differed from group selections more often for the uninsured category than any other. Nevertheless, 89% of participants were willing to abide by the health plan developed by their group. CONCLUSION: In the context of tradeoffs with their own health insurance benefits, groups of Minnesotans presented value-based arguments about covering the uninsured. All 29 groups and two thirds of individuals chose to
contribute a portion of their premium to insure all children and most groups chose also to insure uninsured adults.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1525-1497.2004.32102.x

Comment: Two thirds of us believe in including everyone in the insurance risk pool, and nine tenths of us would be willing to abide by the health plan supported by the two thirds majority. Isn’t that strong enough support to move forward with a program of universal health care coverage?

Pfizer's free drugs and the $800 million pill

Pfizer’s free drugs and the $800 million pill

Pfizer
News Release
July 7, 2004
Pfizer to Launch Comprehensive Initiative Expanding Access to Prescription Medicines for Millions of Americans

Pfizer Inc said today it will launch the pharmaceutical industry’s most comprehensive initiative to significantly expand access to prescription medicines across the United States, with a specific focus on enabling America’s 43 million uninsured to obtain Pfizer medicines at significant savings.

With enrollment beginning in August, Pfizer will provide millions of working families without drug coverage access to Pfizer medicines at an average savings of 37 percent.

“I applaud the steps Pfizer is taking today, which will provide America’s uninsured with access to medicine at significant savings. Pfizer is helping those in dire need get the medicine they often require. This effort holds the promise of helping people in real need, and that is vitally important,” said U.S. Senator Hillary Rodham Clinton (D-NY).

http://www.pfizer.com/are/news_releases/2004pr/mn_2004_0707.html

Frequently Asked Questions about Pfizer Pfriends
Does this new program provide health insurance or coverage for the uninsured?

The actions that Pfizer is taking are a first step, not a total solution for the uninsured. We believe that every American should have access to quality, affordable health insurance. In order to get to a place where every American
has access to quality, affordable health care, we will need to develop a solution that involves government, medical professionals, nonprofits and the private sector. Pfizer is committed to playing an active role in getting to that solution.

http://www.pfizer.com/are/news_releases/2004pr/mn_2004_0707_qa.html

The New York Times
July 8, 2004
Drug Companies Seek to Mend Their Image
By Gardiner Harris

Acknowledging its dismal public standing, Pfizer, the nation’s largest drug company, held a news conference on Wednesday to announce an effort to provide discounted drugs to the working poor and anyone without health insurance.

In a series of presentations, executives at Pfizer, which is based in New York, said yesterday that they were starting the discount program – whose cost will not significantly affect the company’s profits, they said – because it was the right thing to do.

New America Foundation
July 8, 2004
The $800 Million Pill: What Drives the Cost of Prescription Drugs?

Why do life-saving prescription drugs cost so much? Drug companies insist that prices reflect the millions they invest in research and development. In his book The $800 Million Pill, Merrill Goozner contends that American taxpayers are in fact footing the bill twice: once by supporting government-funded research and again by paying astronomically high prices for prescription drugs. Goozner demonstrates that almost all the important new drugs of the past quarter-century actually originated from research at taxpayer-funded universities and at the National Institutes of Health.

He reports that once the innovative work is over, the pharmaceutical industry often steps in to reap the profit. Goozner shows how drug innovation is driven by dedicated scientists intent on finding cures for diseases, not by pharmaceutical firms whose bottom line often takes precedence over the advance of medicine. The $800 Million Pill suggests ways that the government’s role in testing new medicines could be expanded to eliminate the private sector waste driving up the cost of existing drugs.

http://www.newamerica.net/index.cfm?pg=event&EveID=392

Comment: Pfizer’s program creates an administrative nightmare with multiple means-tested programs which will place a significant burden on the health care delivery system. The program will be limited to Pfizer’s products, thereby excluding most prescriptions. Most of the uninsured will still not be able to afford their share of the payment for the drugs in these programs. Since Pfizer has indicated that their generosity will not have a detrimental impact on profits, they obviously realize that this program will have a negligible impact when compared to existing needs.

The conclusions in Merrill Goozner’s report lead to a persuasive argument that Pfizer and the other pharmaceutical firms have an ethical obligation to cooperate with our public agencies in ensuring that everyone has affordable access to essential medications.

Pfizer states that they are “committed to playing an active role” in getting to a solution, which involves the government, wherein every American would, have access to “quality, affordable health insurance.” Pfizer would have more credibility if we saw the least inkling of “playing an active role in getting to that solution.”

Uninsured's ills worsen come bills

Uninsured’s ills worsen come bills
By jspencer@denverpost.com
Jim Spencer
Denver Post Columnist
Friday, July 09, 2004 –

To read Scott Ferguson’s hospital bill is to know the insanity of modern medical economics and the nightmare of 44 million Americans without health insurance.

Here is an albuterol inhaler available at drugstore.com for $13.99. Centura Health’s St. Anthony Central Hospital in Denver charged Ferguson $323.05.

Here is a 30-cent dose of the diuretic Lasix. Centura wanted Ferguson to pay $72.30.

Ferguson, a 51-year-old musician with a heart condition, also got 28-cent tablets of Motrin for $12.70 apiece, $1.73 doses of Ativan for $75.60 a pop and Valium for $79.15 a dose instead of the drugstore.com price of $2.24.

Six hundred milligrams of an antibiotic called Cleocin is readily available at $9.54. Centura’s charge to the uninsured? How does $136.30 grab you?

The bills from a six-day hospitalization for a heart attack last December threatened to grab Ferguson by the bank account and choke the financial life out of him.

That’s why he refused to pay his $67,000 hospital bill. Ferguson discovered that the government health-insurance programs Medicare and Medicaid would only reimburse Centura roughly $6,700 for the services he received.

“I offered them that, plus 30 percent profit,” Ferguson said. “I had the cash to pay them what the insurance companies would have.”

Centura wouldn’t settle, Ferguson said. So Ferguson joined a national lawsuit that challenges discriminatory pricing that victimizes folks already down on their luck.

“I see people destroyed by this,” Ferguson said. “I see no reason for that.”

Centura officials said they couldn’t talk about Ferguson’s case because of the lawsuit. But the people in charge of the Colorado Hospital Association claim this is how it has to be for the uninsured.

“By federal regulation, in order to participate in Medicare, Medicaid and private (health insurance) plans, everybody must be charged the same price,” said Peter Freytag, CHA’s vice president.

But while everyone gets charged the same price, nobody actually pays that price except, perhaps, the uninsured. Government and private insurance companies cut far better deals with hospitals across the country.

In an example that doesn’t involve Centura or Ferguson, records for someone with a private health-insurance plan showed a $16,108 charge for testing blood flow in the patient’s heart. The insurance company paid only $10,470 – $5,638 less than the bill.

To stay in business with so many discounts, Freytag said, hospitals must set prices high. The result is that a portion of all hospital costs are reflected in the charges. That’s why guys like Ferguson get bills of $323 for $14 inhalers.

The inflated charges can get written off as charity or bad debt, Freytag said.

Since joining the lawsuit, Ferguson says he’s heard from plenty of people who paid wacky amounts because of threats from hospital bill collectors.

The whole health-care pricing scheme reminds medical economist J.D. Kleinke of “a psychedelic version of what car dealers do with sticker prices. Everything’s on sale.”

Unless you happen to be uninsured. Then, said Kleinke, you prop up hospitals that remain “incredibly profitable.”

“The Daughters of Charity are known on Wall Street as the Daughters of Currency,” he said.

The answers aren’t easy. A single-payer health-care system would do it, Kleinke said, but Americans don’t seem ready. Meanwhile, regulatory changes that force hospitals to charge the uninsured the Medicaid reimbursement rate will have to do.

One thing is certain: Americans need a change of heart.

“There is,” contended Kleinke, “almost a disdain for the poor.”

Nothing says it better than trying to collect $136.30 for a $9.54 dose of antibiotics.

Jim Spencer’s column appears Mondays, Wednesdays and Fridays. He can be reached at 303-820-177

ABC News' Medical Editor Dr. Tim Johnson says the U.S. health-care system is in Critical Condition

ABC News’ Medical Editor Dr. Tim Johnson says the U.S. health-care system is in Critical Condition.(ABCNEWS)

Peter Jennings Interviews ABCNEWS’Medical Editor on the Health-Care Crisis

Oct. 21 — Did you know that the United States spends more on health care, per capita, than any other country in the world?

Even so, 43 million Americans have no health-care coverage — including one in 10 children. Americans spend $1.6 trillion on health care and much of the system is clearly troubled.

Insurance premiums are going up for the third year in a row. Americans already pay twice as much for prescription drugs as anyone else. The ramifications of all this are huge in the world’s richest nation.

Every other country with a single-payer system, and all of the rich ones do, manage to cover everyone, have universal care, get very good results and do it at a far lower overhead than in the United States have.

This week, every news program on ABCNEWS is taking a closer look at the American health-care system. Peter Jennings interviewed ABCNEWS’ medical editor, Dr. Timothy Johnson for Critical Condition.

Peter Jennings: Tim, you helped us decide on the name of the series, Critical Condition. What is it essentially that is so critical?

Dr. Timothy Johnson: Costs are rising, we’re getting less for our money, we spend twice as much per person on health care in this country than any other industrialized country but we have 43 million uninsured. So we spend a lot of money but we don’t take care of a large section of our population. I think we’re at a critical juncture as to how we should proceed.

Jennings: So you think it’s a critical juncture as well as a critical condition.

Johnson: Yes, I think that’s a fair statement. Certainly for some people it’s a critical condition. The uninsured in our country, we know that they have a 15 to 18 percent mortality rate increase compared to those that are insured. We know that 18,000 of the uninsured die each year in this country for lack of insurance. For them, it’s critical condition. But for the rest of us it’s a critical juncture: What’s going to happen to our health insurance?
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Jennings: Why are so many people in the ABCNEWS poll apparently happy with their health care? [The poll found 64 percent of people with health insurance said they are satisfied with their health care, but 59 percent are worried about being able to afford it in the future.]

Johnson: That’s always been an interesting question. They feel good about their own doctor, their own hospital. But when they start to think about it as a system, and what may happen to their health insurance and their employment, they get worried.

Jennings: Do you see a change in this for a year ago or two years ago?

Johnson: Absolutely. They numbers of concerned are going up. Three years ago, 44 percent were concerned about the overall care in this country, now 54 percent … that’s a 10 percent increase in just three years.

Jennings: The conventional wisdom is Americans like to think that we have the best health-care system in the world.

Johnson: And we do, certainly for people that are very rich or who have very good health insurance and who have very good connections into the health-care system. But for too large a number, 43 million, and many who are underinsured, it is not the very best system in the world.

Jennings: So what was notable in that regard in this poll this time?

Johnson: What was notable is that 62 percent of our population said that they would favor a system of universal health insurance financed by the government, paid for by the tax payers, as opposed to the system we now have, the employer based system where many people are uninsured. I was stunned by that figure.

Jennings: I think conventional wisdom has it that in America, land of the free, that the marketplace is where the price is best established.
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Johnson: That’s true for commodities like a car, where you can go in and make choices and you can even walk out of the showroom if you want. You can’t do that when you’re sick. You can’t do that with health care. So, for health care, you’re talking about a service and here I think the private sector has some real shortcomings. They have to spend a lot of overhead on sales and marketing and choosing the patients they’re going to serve. They shuffle a lot of paperwork. Their administrative paperwork is 15 percent versus the accepted figure of 3 percent for Medicare which is a single payer system where the government handles the money. The delivery system is free. You can pick whatever doctor or hospital you want.

Jennings: Why couldn’t you regard health care as a commodity the way you regard cars?

Johnson: Because in order for it to be a commodity you have to have a consumer who’s informed and can make choices. The consumer can go in and say I want this color, they have the information to make choices; they can walk away from the offered product. Think about getting a colonoscopy, a very common procedure today. Where can you find the Web site that tells you who is the best at it, where it might be the cheapest, who has the most training? The consumer doesn’t have the information to make the choices necessary for a commodity in the free marketplace.

Jennings: Some will say that Americans need to take more personal responsibility for their health care and be better informed.

Johnson: I would not disagree with that. And I think that if we could get better information that will certainly be part of our responsibilities as consumers but right now, that information is very hard to come by. The marketplace doesn’t really exist in terms of consumer information for health care.
PAGEBREAK
Jennings: Now, I think that the conventional wisdom is still the single-payer system, as you and others have described it, is socialized medicine and that isn’t for the U.S.

Johnson: Socialized medicine means that the government both finances health care and owns and operates the doctors and the hospitals.

Jennings: Like Britain?

Johnson: Like Britain. In Canada, it’s a split system. The government indeed does collect the money and disperse it. They run the financial part of health care. But the delivery system is free. People can choose whatever doctor or hospital they want to go to. So, we have a system like that in this country. It’s called Medicare. That’s exactly what happens with Medicare. So, to call the Canadian system socialized is to call Medicare socialized. I think it’s a pejorative word and inaccurate.

Jennings: When I walk past people who know that we’re doing this series this week and I mention the single-payer system, they just say, “Never in America.”

Johnson: I’ve talked to elderly people who say they love Medicare but they don’t want the government involved. They forget that the government has a role to play in setting standards, maybe in handling the money with lower administrative costs. It would be a tragedy for the government to try to run the health-care system in terms of delivery.

Jennings: On top of which, many Americans hold it to be conventional wisdom that private is better than public. Period.

Johnson: In fact the government does a few things well. And I’ll hold up one example in the health-care system: The NIH, the National Institutes of Health, is the shining gem of medical research in this entire world. It’s owned and run by the government. They can do some things well, especially when it comes to health care. Not everything, but some things.

PAGEBREAK

Johnson: And the Republicans in general are very much opposed to that. But at the same time, they realize that Medicare is an example of something that works in part. It needs to be reformed, we need to have a drug benefit, we need to improve the services. They’re behind the times. We need to probably spend more money, believe it or not. At least on some of the administration. But, the same Republicans who don’t want a single-payer system would be loathe to say to our senior citizens, “We’re going to take away from you the one single-payer system we do have” — it’s called Medicare.

Jennings: We’re coming into an election year. It’s clearly a hot political subject. Do you think there is the political will in the country to compromise and provide a system with which all people of all political ideologies would agree?

Johnson: I would like to think so. I’m probably pessimistic about it, but with the latest poll results from our own poll, I’m more optimistic because all of a sudden we have a majority of people who are thinking in that direction. And that is what it’s going to take —a political majority to put pressure on congress. I think the heart of the American people want to do something right, in terms of the uninsured, and I think that the politicians will be dragged along.

Jennings: Conventional wisdom holds that, I think, that with the uninsured, they still have access to American medical care, they have it in the emergency room.
PAGEBREAK

Johnson: I would call that a real misunderstanding. It is true. We do not let people die in the streets if they get sick enough, they will get to the emergency room, but all too often by that time, they’re so much sicker that their outcomes are less assured. It’s going to cost a lot more money to take care of them. We have access through the emergency room, but if we could have it earlier through insurance coverage we could provide it at less cost, with better outcomes and with more dignity.

Jennings: If the uninsured are crowding the emergency rooms for basic care, is that adding to the cost of health care for the rest of us?

Johnson: It is. Somebody has to pay those bills, obviously. And it falls on local and state and to some degree, federal governments. But we pay a much higher price, I think, in the moral issue involved and the medical outcomes involved.

Health Versus Wealth

Health Versus Wealth
July 9, 2004

Will actual policy issues play any role in this election? Not if the White House can help it. But if some policy substance does manage to be heard over the clanging of conveniently timed terror alerts, voters will realize that they face some stark choices. Here’s one of them: tax cuts for the very well-off versus health insurance.

John Kerry has proposed an ambitious health care plan that would extend coverage to tens of millions of uninsured Americans, while reducing premiums for the insured. To pay for that plan, Mr. Kerry wants to rescind recent tax cuts for the roughly 3 percent of the population with incomes above $200,000.

George Bush regards those tax cuts as sacrosanct. I’ll talk about his health care policies, such as they are, in another column.

Considering its scope, Mr. Kerry’s health plan has received remarkably little attention. So let me talk about two of its key elements.

First, the Kerry plan raises the maximum incomes under which both children and parents are eligible to receive benefits from Medicaid and the State Children’s Health Insurance Program. This would extend coverage to many working-class families, who often fall into a painful gap: they earn too much money to qualify for government help, but not enough to pay for health insurance. As a result, the Kerry plan would probably end a national scandal, the large number of uninsured American children.

Second, the Kerry plan would provide ”reinsurance” for private health plans, picking up 75 percent of the medical bills exceeding $50,000 a year. Although catastrophic medical expenses strike only a tiny fraction of Americans each year, they account for a sizeable fraction of health care costs.

By relieving insurance companies and H.M.O.’s of this risk, the government would drive down premiums by 10 percent or more.

This is a truly good idea. Our society tries to protect its members from the consequences of random misfortune; that’s why we aid the victims of hurricanes, earthquakes and terrorist attacks. Catastrophic health expenses, which can easily drive a family into bankruptcy, fall into the same category. Yet private insurers try hard, and often successfully, to avoid covering such expenses. (That’s not a moral condemnation; they are, after all, in business.)

All this does is pass the buck: in the end, the Americans who can’t afford to pay huge medical bills usually get treatment anyway, through a mixture of private and public charity. But this happens only after treatments are delayed, families are driven into bankruptcy and insurers spend billions trying not to provide care.

By directly assuming much of the risk of catastrophic illness, the government can avoid all of this waste, and it can eliminate a lot of suffering while actually reducing the amount that the nation spends on health care.

Still, the Kerry plan will require increased federal spending. Kenneth Thorpe of Emory University, an independent health care expert who has analyzed both the Kerry and Bush plans, puts the net cost of the plan to the federal government at $653 billion over the next decade. Is that a lot of money?

Not compared with the Bush tax cuts: the Center on Budget and Policy Priorities estimates that if these cuts are made permanent, as the administration wants, they will cost $2.8 trillion over the next decade.

The Kerry campaign contends that it can pay for its health care plan by rolling back only the cuts for taxpayers with incomes above $200,000. The nonpartisan Tax Policy Center, which has become the best source for tax analysis now that the Treasury Department’s Office of Tax Policy has become a propaganda agency, more or less agrees: it estimates the revenue gain from the Kerry tax plan at $631 billion over the next decade.

What are the objections to the Kerry plan? One is that it falls far short of the comprehensive overhaul our health care system really needs. Another is that by devoting the proceeds of a tax-cut rollback to health care, Mr. Kerry fails to offer a plan to reduce the budget deficit. But on both counts Mr. Bush is equally, if not more, vulnerable. And Mr. Kerry’s plan would help far more people than it would hurt.

If we ever get a clear national debate about health care and taxes, I don’t see how President Bush will win it.

URL: http://www.nytimes.com